Arachnoid Remodeling by Clipping Technique Facilitates Surgical Maneuverability during Transsphenoidal Surgery for Pituitary Macroadenoma

Objective@#: Pituitary adenomas frequently extend into the suprasellar space. After a suprasellar tumor is removed, the superiorly extended arachnoid becomes redundant and sinks down into the intrasellar space which often hiders visualization and accessibility to the hidden space behind the evaginated arachnoid. We introduced arachnoid remodeling by clipping technique, and evaluated its usefulness and safety during TSS. @*Methods@#: Total 223 patients who underwent arachnoid remodeling with our new clipping technique were included. Redundant arachnoid was clipped along the dural edge with multiple 2.6-mm titanium clips until the redundant arachnoid membrane no longer blocked the surgical route. To check for possible deterioration of hormonal function by this technique, we assessed anterior pituitary function of 166 patients who underwent arachnoid remodeling by clipping and compared this with those of other 429 control patients. @*Results@#: Our technique greatly enhanced the accessibility and visualization of intrasellar and parasellar spaces, both of which are generally hindered by redundant arachnoid during transsphenoidal surgery (TSS). We found no difference in anterior pituitary function between a clip-assisted arachnoid remodeling group and the control group, implying that this technique does not result in hypopituitarism. @*Conclusion@#: During TSS for pituitary adenomas with suprasellar extension, arachnoid remodeling by clipping technique is very useful and convenient for the management of the redundant arachnoid membrane to enhance visualization and surgical accessibility.

Angioleiomyoma in the Orbital Apex: A Case Report

A 56-year woman presented eyeball pain and blurred vision. MRI revealed a small well-delineated solid tumor in the apex of right orbit with optic nerve compression. Intraoperatively, the tumor was found very fibrous, hypervascular and adhesive to surrounding structures. The tumor was completely removed with the combination of endoscopic and microscopic technique. Patient experienced transient oculomotor nerve palsy, which completely recovered 3 months after surgery. Herein we report a rare case of angioleiomyoma in the orbital apex.

Vestibular Schwannoma Atypically Invading Temporal Bone

Vestibular schwannoma (VS) usually present the widening of internal auditory canal (IAC), and these bony changes are typically limited to IAC, not extend to temporal bone. Temporal bone invasion by VS is extremely rare. We report 51-year-old man who revealed temporal bone destruction beyond IAC by unilateral VS. The bony destruction extended anteriorly to the carotid canal and inferiorly to the jugular foramen. On histopathologic examination, the tumor showed typical benign schwannoma and did not show any unusual vascularity or malignant feature. Facial nerve was severely compressed and distorted by tumor, which unevenly eroded temporal bone in surgical field. Vestibular schwannoma with atypical invasion of temporal bone can be successfully treated with combined translabyrinthine and lateral suboccipiral approach without facial nerve dysfunction. Early detection and careful dissection of facial nerve with intraoperative monitoring should be considered during operation due to severe adhesion and distortion of facial nerve by tumor and eroded temporal bone.

Granular Cell Tumor in the Pituitary Stalk: A Case Report

Granular cell tumors (GCTs) have been reported in various tissues, especially the skin and subcutaneous soft tissue of the head and neck. We report a 60-year-old man who presented with intermittent headache and dizziness for 3 months, but no other neurological symptoms. Magnetic resonance imaging (MRI) showed the presence of a mass in the pituitary stalk, and contrast-enhanced MRI showed nodular enhancement in this region. The lesion was completely excised microscopically via a frontotemporal (pterional) approach. On pathological examination, a final diagnosis of a typical GCT was made.

Association of nasal inflammation and lower airway responsiveness in schoolchildren based on an epidemiological survey

BACKGROUND/AIMS: We sought to increase our understanding of the rhinitis-asthma relationship and improve strategies for the treatment of patients with these diseases. The aim of this study was to identify a connection between upper airway inflammation and lower airway responsiveness. METHODS: We counted eosinophils on nasal smears, and performed spirometry, allergic skin tests, and methacholine challenge tests in 308 schoolchildren plus a questionnaire on respiratory symptoms. The methacholine concentration causing a 20% fall in forced expiratory volume in 1 second (PC20 0.05). No difference in BHR was detected when comparing subjects with and without nasal eosinophils. There were significant differences in the PC20 between subjects with greater than 50% nasal eosinophils and without nasal eosinophils (11.01 +/- 2.92 mg/mL vs. 17.38 +/- 0.61 mg/mL; p < 0.001). CONCLUSIONS: These findings demonstrated that nasal eosinophilic inflammation might contribute to lower airway responsiveness in schoolchildren, based on an epidemiological survey.

Long-Term Outcomes of Cytomegalovirus Reactivation in Patients with Moderate to Severe Ulcerative Colitis: A Multicenter Study

BACKGROUND/AIMS: Cytomegalovirus (CMV) reactivations are frequently observed in patients with active ulcerative colitis (UC), and ganciclovir therapy is effective in patients with steroid-refractory UC. This study aimed to determine the long-term outcomes of CMV reactivation and the long-term therapeutic efficacy of ganciclovir treatment. METHODS: This retrospective multicenter study included a cohort of 72 patients with moderate-to-severe UC who were evaluated for CMV reactivation at the time of their initial UC flare. Colectomy, disease relapse, and the recurrence rate of CMV reactivation were investigated. RESULTS: The mean duration of follow-up for the 72 patients was 43.16+/-19.78 months (range, 1 to 67 months). The cumulative colectomy (log-rank, p=0.025) and disease flare-up rates (log-rank, p=0.048) were significantly higher in the CMV-positive group. Of the 11 patients who were successfully treated with ganciclovir in the initial treatment, three patients (27.3%) experienced CMV reactivation, and six patients (54.5%) experienced poor outcomes, such as the need for colectomy or a steroid-dependent state. CONCLUSIONS: The patients who had CMV-reactivated UC showed poor outcomes at the long-term follow-up, and the long-term efficacy of ganciclovir therapy was marginal. Careful assessment is necessary for patients who exhibit evidence of CMV reactivation.

Reasons for Investigators to Participate Industry Sponsored Clinical Trials

BACKGROUND: It is getting more difficult to involve appropriate investigators in clinical trials. Knowing what investigators want from sponsor initiated clinical trials would help industry cooperate with investigators more efficiently. This study aims to describe the incentives for investigators choosing to participate or not and perform well in sponsored clinical trials. METHODS: Investigators who have participated in GSK sponsored clinical trials were interviewed face-to-face or through e-mail using the standardized questionnaire. Investigators were asked to choose five items and determine the ranking or those five items. RESULTS: Questionnaires answered by 122 investigators were collected. The top three incentives were "Academic merit" (108, 88.5 %), "Expectation of treatment potentially helpful to patient" (101, 82.8 %), and "Access to new treatments" (92, 75.4 %). The disincentives and the factors affecting an investigator's performance were analyzed separately because of the different questionnaire between investigators for medicine and vaccine. Investigators for medicine choose as disincentives "Insufficient time" (43, 61.4 %), "Difficult protocol" (41, 58.6 %), and "Adverse event concerns" (41, 58.6 %). Vaccine investigators pointed out "Limited support staff" (41, 78.8 %), "Insufficient time" (40, 76.9 %), and "Difficult blood sampling" (333, 63.5 %) as disincentives. Factors adversely affecting an investigator's performance showed similar results to those of disincentives. CONCLUSION: Investigators focused on academic curiosity and patients and insufficient time mostly inhibits them from participating and performing clinical trials. Our results would help industry cooperate with investigators more efficiently, finally making companies perform clinical trials more effectively.

The Rapid Establishment of Human Clonal Adipose Derived Stem Cell (hADSC) Lines with Aspirated Adipose Tissue

PURPOSE: This study aims to establish a new strategy that provides for the rapid establishment of human clonal adipose derived stem cell (hADSC) lines with aspirated adipose tissue and to characterize newly generated hMSC lines for their cell phenotype, differentiation potential, lineage-specific gene expression. METHODS: Human adipose tissue-derived stem cells (hADSCs) were isolated from subcutaneous adipose tissue based on standard protocols. After incubation for 2 h, only the cell culture supernatant was transferred to a new dish. This process was repeated several times with 30 h incubations. RESULTS: We confirmed the difference in growth rate, however, differences were not seen in the differentiation capabilities and stemness of the each cell lines. CONCLUSION: It is necessary to establish cell lines via single cell level for application to disease specific tissue engineering.

Factors Affecting the Ocular Response Analyzer Parameters in Normal Korean

PURPOSE: To identify the normal range of factors which can be measured with Ocular Response Analyzer (ORA, Reichert Inc., Depew, NY, USA) in normal Korean, and to analyze factors affecting ORA by measuring intraocular pressure (IOP) of noncontact tonometer (NCT) and central corneal thickness (CCT). METHODS: Three hundred and one normal Korean subjects who did not have specific ophthalmological diseases and surgeries in the past were recruited for this study. Corneal hysteresis (CH), corneal response factor (CRF), corneal-compensated IOP (IOPcc), and Goldmann correlated IOP (IOPg) were measured using ORA. In addition, IOP of NCT and CCT were measured and the results and factors analyzed. RESULTS: The mean CH measured among normal Korean subjects in this study was 10.70 mmHg. The mean CRF was 10.40 mmHg. CH and CRF were significantly higher in the juvenile group. IOPcc and IOPg as measures of IOP using the ORA had significant correlation with IOP of NCT. In particular, IOPcc appeared to be independent of CCT. CONCLUSIONS: CH and CRF were different according to age, indicating a difference in biomechanical properties of the cornea. In particular, IOPcc is more important as it is independent of corneal thickness and should be compensated in general measurements of IOP reflecting biomechanical properties.

Complete Hematopoietic Recovery after Continuous Iron Chelation Therapy in a Patient with Severe Aplastic Anemia with Secondary Hemochromatosis

A 16-yr-old male patient with hemochromatosis due to multiple packed red blood cell transfusions was referred to our emergency center for the treatment of severe aplastic anemia and dyspnea. He was diagnosed with aplastic anemia at 11-yr of age. He had received continuous transfusions because an HLA-matched marrow donor was unavailable. Following a continuous, approximately 5-yr transfusion, he was noted to develop hemochromatosis. He had a dilated cardiomyopathy and required diuretics and digitalis, multiple endocrine and liver dysfunction, generalized bleeding, and skin pigmentation. A total volume of red blood cell transfusion before deferoxamine therapy was about 96,000 mL. He received a regular iron chelation therapy (continuous intravenous infusion of deferoxamine, 50 mg/kg/day for 5 days q 3-4 weeks) for approximately seven years after the onset of multiple organ failures. His cytopenia and organ dysfunctions began to be gradually recovered since about 2002, following a 4-yr deferoxamine treatment. He showed completely normal ranges of peripheral blood cell counts, heart size, and liver function two years ago. He has not received any transfusions for the last four years. This finding suggests that a continuous deferoxamine infusion may play a role in the immune regulation in addition to iron chelation effect.

Hepatitis B virus reactivation during chlorambucil and prednisolone treatment in an HBsAg-negative and anti-HBs-positive patient with B-cell chronic lymphocytic leukemia / 대한간학회지

It is generally accepted that seroconversion of hepatitis B virus (HBV) surface antigen (HBsAg) to an antibody to HBsAg (anti-HBs) indicates clearance of HBV. Here we report a case of severe hepatitis that manifested during chemotherapy in a female patient with chronic lymphocytic leukemia (CLL) who had been initially seronegative for HBsAg and seropositive for anti-HBs. The patient received chlorambucil and prednisolone for the treatment of CLL. After 6 months the serum levels of aminotransferases were increased, and HBsAg and HBV DNA were present in serum. Lamivudine was administered immediately after confirming the HBV reactivation, which considerably improved jaundice and aminotransferase levels after 3 weeks. The patient was able to resume the chemotherapy whilst continuing lamivudine treatment. This case report highlights the need for physicians to be aware of the potential risk of HBV reactivation even in an HBsAg-negative person but with detectable anti-HBc and/or anti-HBs, underscoring the need for future studies that explore the role of antiviral prophylaxis in this setting.

Hematopoietic Effects of Valproic Acid in Mouse / 대한소아혈액종양학회지

PURPOSE: Valproic acid (VPA) has been used as an anticonvulsant for a long time. Recently, there are many reports on VPA activity with regards to intracellular signal transduction, including differentiation, proliferation, and apoptosis. We experienced several hematologic toxicities during the long-term use of VPA. Therefore, we investigated whether VPA has effects on short-term or long-term hematopoiesis with respect to differing concentrations. METHODS: We obtained bone marrow mononuclear cells (BMMNC) from a 5 week old female C3H/He strain mouse. The BMMNC were cultured in semi-solid media mixed with VPA according to the concentrations of colony forming unit for granulocyte-monocytes (CFU-GM). The concentrations of VPA were used as follows: 0.01 mM, 0.1 mM, 1 mM, and 10 mM (therapeutic level: 0.07~1.1 mM). We performed long-term liquid culture under VPA to compare the frequency of long-term culture initiating cells (LTC-IC) according to various VPA levels. RESULTS: The number of CFU-GM was highest with 1 mM of VPA (45.2+/-13.5), with higher therapeutic level than control (25.7+/-11.9), in 0.01 mM of VPA (26.5+/-12.1) and in 0.1 mM of VPA (26.6+/-12.2). In 10 mM of VPA, a toxic level of VPA, was the lowest at 1.6+/-1.1 (P< 0.01). In long-term culture, the frequency of LTC-IC was increased in 0.1 mM of VPA (67.7+/-16.3%), lower therapeutic level than in control (5.5+/-10.6%). In 1 mM of VPA, the high therapeutic level decreased to 81.6+/-9.3%. With toxic levels of VPA, 10 mM, there was no hematopoiesis. CONCLUSION: The VPA might enhance short-term hematopoiesis at high therapeutic levels, while preserving LTC-IC in long-term hematopoiesis under low therapeutic concentrations. Therefore, we suggest that VPA to be used within a low therapeutic level to escape from hematopoietic suppression when using VPA as long-term medication for seizure control.

The Long Term Remission Effect of Rituximab in Two Patients with Autoimmune-associated Cytopenias that were Refractory to Standard Treatments

Rituximab, anti-CD20 chimeric monoclonal antibody directed against the CD20 antigen on B lymphocytes, induces a targeted B lymphocytes depletion in the aim of eradicating autoreactive clones in various autoimmune disorders. Because of its biological properties, it has been used as a treatment option for a variety of autoimmune diseases. We report two complicated patients: a 26-year-old female with steroid induced Cushing's syndrome and avascular necrosis of both femur heads, and a 56-year-old female with multiple spine compression fractures due to osteoporosis, diabetes mellitus and cataracts. They had long lasting, more than 10 years, lupus-associated hemolytic anemia and Evans syndrome, refractory to corticosteroids and immunosuppressive agents. The patients were treated with Rituximab, 375mg/m2 once weekly for 3 consecutive weeks. They showed a remarkable recovery about 5th week and have been free of transfusion after the treatment with Rituximab. Therapy was well tolerated, and no infectious complications occurred. They are still in complete remission at 20 and 4 months following the treatment, respectively. We suggest that Rituximab can be a valuable agent in the management of autoimmune cytopenias refractory to standard treatments.

Effects of Cyclosporin A, FK506, and 3-Deazaadenosine on Acute Graft-versus-host Disease and Survival in Allogeneic Murine Hematopoietic Stem Cell Transplantation

BACKGROUND: We investigated the effect of donor marrow T cell depletion, administration of FK506, cyclosporin A (CSA), and 3-deazaadenosine (DZA) on graft versus host disease (GVHD) after allogeneic murine hematopoietic stem cell transplantation (HSCT). METHODS: We used 4 to 6 week old Balb/c (H-2(d), recipient), and C3H/He (H-2(k), donor) mice. Total body irradiated recipients received 1x10(7) bone marrow cells (BM) and 0.5x10(7) splenocytes of donor under FK506 (36 mg/kg/day), CSA (5 mg/kg/day, 20 mg/kg/day), and DZA (45 mg/kg/day), which were injected intraperitoneally from day 1 to day 14 daily and then three times a week for another 2 weeks. To prevent the GVHD, irradiated Balb/c mice were transplanted with 1x10(7) rotor-off (R/O) cells of donor BM. The severity of GVHD was assessed daily by clinical scoring method. RESULTS: All experimental groups were well grafted after HSCT. Mice in experimental group showed higher GVHD score and more rapid progression of GVHD than the mice with R/O cells (R/O group) (p<0.01). There were relatively low GVHD scores and slow progressions in FK506 and low dose CSAgroups than high dose CSA group (p<0.01). The survival was better in FK506 group than low dose CSA group. All mice treated with CSA died within 12 days after HSCT. The GVHD score in DZA group was low and slow in comparison with control group (p<0.05), but severity and progression were similar with low dose CSA group (p=0.11). All mice without immunosuppressive treatment died within 8 days, but all survived in R/O group (p<0.01). Survival in low dose CSA group was longer than in control group (p<0.05), but in high dose CSA group, survival was similar to control group. The survival benefit in DZA group was similar with low dose CSA group. FK506 group has the best survival benefit than other groups (p<0.01), comparable with R/O group (p=0.18), although probability of survival was 60%. CONCLUSION: We developed lethal GVHD model after allogeneic murine HSCT. In this model, immunosuppressive agents showed survival benefits in prevention of GVHD. DZA showed similar survival benefits to low dose CSA. We propose that DZA can be used as a new immunosuppressive agent to prevent GVHD after allogeneic HSCT.

Inhibition of Graft Versus Host Disease Using CD4+ CD25+ T Cells Induced with Interleukin-2 in Mismatched Allogeneic Murine Hematopoietic Stem Cell Transplantation

BACKGROUND: In kidney transplantation, donor specific transfusion may induce tolerance as a result of some immune regulatory cells against the graft. In organ transplantation, the immune state arises from a relationship between the immunocompromised graft and the immunocompetent host. However, a reverse immunological situation exists between the graft and the host in hematopoietic stem cell transplantation (HSCT). In addition, early IL-2 injections after an allogeneic murine HSCT have been shown to prevent lethal graft versus host disease (GVHD) due to CD4+ cells. We investigated the induction of the regulatory CD4+CD25+ cells after a transfusion of irradiated recipient cells with IL-2 into a donor. METHODS: The splenocytes (SP) were obtained from 6 week-old BALB/c mice (H-2(d)) and irradiated as a single cell suspension. The donor mice (C3H/ He, H-2(k)) received 5x10(6) irradiated SP, and 5,000 IU IL-2 injected intraperitoneally on the day prior to HSCT. The CD4+CD25+ cell populations in SP treated C3H/He were analyzed. In order to determine the in vivo effect of CD4+CD25+ cells, the lethally irradiated BALB/c were transplanted with 1x10(7) donor BM and5x10(6) CD4+CD25+ cells. The other recipient mice received either 1x10(7) donor BM with 5x10(6) CD4+ CD25- cells or the untreated SP. The survival and GVHD was assessed daily by a clinical scoring system. RESULTS: In the MLR assay, BALB/c SP was used as a stimulator with C3H/He SP, as a responder, with or without treatment. The inhibition of proliferation was 30.0 13% compared to the control. In addition, the MLR with either the CD4+CD25+ or CD4+CD25- cells, which were isolated by MidiMacs, from the C3H/He SP treated with the recipient SP and IL-2 was evaluated. The donor SP treated with the recipient cells and IL-2 contained more CD4+CD25+ cells (5.4+/-1.5%) than the untreated mice SP (1.4+/-0.3%)(P<0.01). There was a profound inhibition in the CD4+CD25+ cells (61.1+/-6.1%), but a marked proliferation in the CD4+CD25- cells (129.8+/-65.2%). Mice in the CD4+CD25+ group showed low GVHD scores and a slow progression from the post-HSCT day 4 to day 9, but those in the control and CD4+CD25- groups had a high score and rapid progression (P<0.001). The probability of survival was 83.3% in the CD4+CD25+ group until post-HSC day 35 and all mice in the control and CD4+CD25- groups died on post-HSCT day 8 or 9 (P=0.0105). CONCLUSION: Donor graft engineering with irradiated recipient SP and IL-2 (recipient specific transfusion) can induce abundant regulatory CD4+CD25+ cells to prevent GVHD.

The role of mesenchymal stem cells in hematopoietic stem cell transplantation / 대한내과학회지

BACKGROUND: Human bone marrow contains mesenchymal stem cells (MSCs) which are capable of differentiation into a number of mesenchymal cell lineages when stimulated under appropriate conditions. Many studies indicate that the bone marrow stroma is damaged following bone marrow transplantation. Animal models suggest that the transplantation of healthy stromal elements, including MSCs, may enhance the ability of the bone marrow microenvironment to support hematopoiesis after stem cell transplantation. However, it remains to be seen whether transplantation of MSCs has significant value and pre-culture of hematopoietic stem cells with MSCs prior to transplantation changes their engraftment. METHODS: We investigated the differentiation potential and the potential plasticity of MSCs. And we also studied whether they have any effects on hematopoietic engraftment in xenotransplantation animal model. RESULTS: Culture-expanded human MSCs exhibited a spindle-shaped fibroblastic morphology and were differentiated into adipocytes, osteoblasts, and chondrocytes in specific culture conditions. In xenograft animal model, human ex vivo expanded marrow-derived MSCs were cotransplantated with human CD34+ cells into NOD/SCID mice and demonstrated about a two-fold increase in bone marrow engraftment as determined by human CD45+ and CD34+ expression as compared to transplantation of CD34+ cells alone. Also MSCs resulted in a two-fold to three-fold increase in bone marrow engraftment of CD45+- CD33+ cells and CD45+- CD13+ cells, whereas no such effect were observed in engraftment of CD45+- CD3+ cells and CD45+- CD19+ cells. To determine the homing and engraftment of MSCs, we performed cotransplantation of human CD34+ cells with ex vivo expanded human MSCs that had been retrovirally transduced with GFP transgene into NOD/SCID mice. Expression of GFP was found in the bone marrow of 1 of 5 NOD/SCID mice by DNA-PCR analysis. Using DNA-PCR, we found human beta2-microglobulin expression in liver, spleen, thymus, lung, heart, kidney, and small intestine. CONCLUSION: These results suggest that MSCs are capable of enhancing hematopoietic engraftment and they also may possess therapeutic value for the repair of damaged mesenchymal tissues following hematopoietic stem cell transplantation.

Induction Chemotherapy for Patients with Acute Myeloid Leukemia Aged over 60 Years / 대한혈액학회지

BACKGROUND: Clinical and biologic characteristics of elderly patients with acute myeloid leukemia (AML) have not been well defined yet and there is no consensus on the appropriate treatment approach. We analyzed the outcome of these patients in terms of complete remission (CR) and the long-term life expectancy. METHODS: Twenty patients received mitoxantrone at the dose range of 4~8 mg/m2/ day for 3 days according to the patients' condition based on age and performance status, low-dose cytosine arabinoside 10mg/m2 subcutaneously at every 12 hours for 10~14 days, and etoposide 100mg/day per os for 10~14 days. Most of patients achieving CR received at least 1~3 more courses of post-remission therapy with same initial regimen. Nine out of 17 patients receiving more than two courses of post-remission chemotherapy received their cryopreserved peripheral bloods stem cells after the second or third consolidation chemotherapy. RESULTS: Overall, CR was achieved in 16 (80%) out of 20 patients and the median CR duration was 6 months (range 2~17 months). The most frequent complication during the induction chemotherapy was pneumonia (55%). CONCLUSION: The induction chemotherapy regimen including mitoxantrone, cytosine arabinoside, and etoposide seems to be promising in elderly AML patients in terms of CR rate, while its duration was short. Hopefully, it is necessary to develop a new post-remission therapy to maintain long-term disease-free survival in elderly AML patients.

Analysis of T Lymphocyte Subsets Following Antilymphocyte Globulin and Cyclosporine A Therapy in Patients with Aplastic Anemia / 대한혈액학회지

BACKGROUND: Immunosuppression of hematopoiesis has been regarded as one of the most important pathogenetic mechanisms of idiopathic aplastic anemia. This investigation intended to examine the immunological pathogenesis of aplastic anemia and discover the therapeutic mechanism and predictor factors for the combined therapy of antilymphocyte globulin (ALG) and cyclosporine A through observing the changes of T lymphocyte subsets in the peripheral blood before and after the combining therapy of ALG and cyclosporine A. METHODS: Comparisons and analyses were made after measuring CD4+ T-lymphocytes and CD8+ T-lymphocytes by the flow-cyto metry after gathering the peripheral blood from 17 aplastic anemia patients, who were treated with a combining therapy of ALG and cyclo sporine A at the Hematopoietic Stem Cell Transplatation Center of St. Mary's hospital, Catholic University, from August 2000 through November 2000. These were conducted prior to treatment, immediately after the therapy and 3 months later. Fifteen healthy bone marrow do nors were selected as a normal control group. RESULTS: With respect to comparing T lymphocyte subsets between the aplastic anemia patient group and the normal control group in the peripheral blood, the CD4+ T lymphocytes ratio and the absolute numbers decreased significantly for the aplastic anemia patient group, as opposed to that of the normal control group (P=0.0001, P=0.0003). The CD8+ T lymphocytes ratio and the absolute numbers increased significantly for the response group (complete response group and partial response group) than that of the control group (P=0.0003, P=0.0295). Regarding the ratio of CD4+ T lymphocytes to CD8+ T lymphocytes, the aplastic anemia patients group showed a significant decrease comparing to that of the control group with 0.79+/-0.32 and 1.41+/-0.24 respectively (P=0.0001). The therapyresponding rate for ALG and cyclosporine A was 70.59% (complete response rate, 23.53%; partial response rate, 47.06%). There were no critical complications to be considered as limiting factors for the therapy. The CD8+ T lymphocytes ratio and absolute numbers already increased before the therapy for the better response group (P=0.0001, r=0.791; P=0.008, r=0.616). The ratio between CD4+ T lymphocytes and CD8+ T lymphocytes was decreased comparing the other two groups as 0.57+/-0.18 in the complete response group before the treatment was implemented. However, there was no statistically significant difference (P=0.30). The ratio of CD8+ T lymphocytes 3 months after the therapy decreased by three-folds in the response group as compared with that of the non-response group before the therapy. The ratio between CD4+ T lymphocytes and CD8+ T lymphocytes improved more than that of the other two groups (1.00+/-0.70) for the complete response group (P=0.0046). CONCLUSION: The imbalance of the lympho cyte subset shown as the ratio between the CD4+ T lymphocytes and the CD8+ T lymphocytes decreased secondary to the decrease of CD4+ T lymphocytes as well as the increase of CD8+ T lymphocytes were believed to be the factors that caused marrow failure among others. The ratio between CD4+ T lymphocytes and CD8+ T lymphocytes can be improved by removing CD8+ T lymphocytes, which increased by the combining therapy of ALG and cyclosporine A. These results may help predict the therapeutic effects by way of analyzing the T-lymphocyte subsets in the peripheral blood prior to implementing the therapy.

Busulfan, thiotepa, and melphalan as a conditioning regimen for allogeneic bone marrow transplantation in patients with acute myelogenous leukemia / 대한내과학회지

BACKGROUND: The purpose of this study was to evaluate the toxicity and efficacy of high-dose chemotherapy with busulfan, thiotepa and melphalan (BTM) as a myeloablative regimen in allogeneic bone marrow transplantation (allo-BMT) for patients with acute myelogenous leukemia (AML). METHODS: Twenty-seven patients with AML were enrolled; Sixteen patients had standard risk (SR) diseases (first complete remission (CR1) and de novo AML) and eleven patients had high risk (HR) diseases (second, or subsequent remission, secondary AML, relapsed, or refractory AML, CR marrow with persisting extramedullary manifestation (chloroma), or hypoplastic acute leukemia). The conditioning regimen included busulfan 4 mg/kg/day for a total dose of 12 mg/kg; thiotepa 250 mg/m2/day for a total dose of 500 mg/m2; and melphalan 50 mg/m2/day for a total dose of 100 mg/m2. Cyclosporine A and short-course methotrexate were used for graft-versus-host disease (GVHD) prophylaxis. RESULTS: The median time to recovery a granulocyte count of 0.5 x 109/L was 14 days (range 10~25 days) and platelet transfusion independence was 30 days (range 12~49 days). The major regimen-related toxicities were gastrointestinal-related symptoms including oral mucositis, nausea, vomiting, and diarrhea. All patients experienced oral mucositis (> or = grade 1) and the patients with oral mucositis of equal and greater than grade 3 were 44% in SR and 45% in HR. The toxicities associated with lung, skin, heart and brain were minimal. Three (11%) patients had severe or fatal veno-occlusive disease (VOD). There were five treatment-related death (19%) (hepatic VOD with multiorgan failure (n=3), pneumonia and ARDS (n=2)) within the first 100 days after allo-BMT. There was not a significant difference between SR and HR group (p=0.167). The incidence of acute GVHD equal or greater than grade II was less than 10%. The actual survival at 2 year was 70.4%(95% confidence interval (CI), 54.7%~86.1%)(SR; 81.3% (95% CI; 63.4~99.1%) vs HR; 54.6% (95% CI; 28.7~80.4%), p=0.154). After a median follow-up of 630 days, 18 of 27 (67%, 355~1062 days) patients are alive without evidence of disease. Three of the 27 patients relapsed (SR; 0% vs HR; 55.6% (95% CI; 19.6~71.3%), p=0.004). CONCLUSION: The BTM regimen followed by allo-BMT is associated with acceptable toxicity and appears to have significant activity in patients with AML. It should be used with caution in patients with prior hepatopathy or refractory state who have an increased risk of severe VOD. Busulfan, thiotepa, and melphalan is an effective and alternative myeloablative regimen for patients with AML.

Platelet agglutinating protein (PAP p37) from a patient with thrombotic thrombocytopenic purpura is identical with prethrombin 2 / 대한내과학회지

BACKGROUND: Thrombotic thrombocytopenic purpura (TTP) is characterized by widespread platelet thrombi with little fibrin in the arterioles and capillaries. Unusually large or multimeric von Willebrand factor (vWF) and one or more platelet-agglutinating factors have been implicated in the pathogenesis of TTP. However, there had not been any satisfactory explanations regarding the actual mechanisms of platelet agglutination until now. Recent studies suggested 37 kDa platelet agglutinating protein (PAP p37) to be responsible for the formation of platelet thrombi in the patients with TTP. We already purified and reported 37 kDa platelet agglutinating protein (PAP p37) in a patient with TTP. To identify PAP p37, we studied more characteristics and sequenced N-terminal 21 amino acid residues of PAP p37. METHODS: PAP p37 was purified from the plasma which was obtained during the first plasmapheresis in a 31-year-old male Korean patient with acute TTP by ammonium sulfate fractionation, DEAE-Sephacel, concanavalin A-Sepharose and Superose 12 gel filteration chromatographies. In each step, agglutinating activity of platelet was studied by platelet aggregometer. N-terminal 21 amino acid of PAP p37 was sequenced using automatic amino acid sequence analyzer (Beckmann, USA), Sequence Homology Analysis (NCBI BLAST 2.0 from http://www.ncbi.nlm.nih.gov/BLAST1), and Multiple Sequence Alignment (GeneDoc 2.6.0 from http://www.psc.edu/biomed/genedoc/). After we found out that the amino acid sequence of PAP p37 is identical with prothrombin 285-305 amino acid sequence, prothrombin gene was sequenced by the Amersham and CircumVent thermal cycle DNA sequencing kit for detecting gene mutation. RESULTS: The results are as follows: 1) N-terminal 21 amino acid sequence of PAP p37 was T-F-G-S-G-E-A-D-X-G-L-R-P-L-F-E-K-K-S-L-E and appeared to be identical to that of 285-305 amino acid residues of human prothrombin (prethrombin 2) Compared with thrombin by SDS-PAGE with or without beta-mercaptoethanol, PAP p37 was suggested that is unsuccessfully cleaved thrombin light chain which was not cleaved disulfied bond between A-chain and B-chain in prethrombin 2. 2) No gene DNA mutation was found in any prothrombin gene. 3) PAP p37 revealed competitive binding against anti-thrombin antibody with thrombin by ELISA method and their antigenicity was similar with thrombin. CONCLUSION: PAP p37 has potent platelets agglutinating activity and the N-terminal 21 amino acid residues, the pattern of SDS-PAGE with beta-mercaptoethanol and the antigenicity were the same as prethrombin 2 of procoagulant. This prethrombin 2 in TTP may develop due to unsuccessful cleaving of the thrombin light chain. These results suggest that there are defects in procoagulant proteolysis of TTP.