Successful treatment of disseminated cerebritis complicating methicillin-resistant Staphylococcus aureus Endocarditis unresponsive to vancomycin therapy with linezolid.

A unique case of community acquired methicillin resistant Staphylococcus aureus (MRSA) sepsis, with endocardial and cerebral metastatic seeding, caused by a strain representative of the Italian clone, is described. The patient was a 47-y-old man without apparent risk factors for endocarditis and for MRSA infection who developed coma with multiple cerebritis lesions under vancomycin plus amikacin therapy. He was eventually cured with the addition of linezolid to the initial antimicrobial regimen. This observation seems to confirm previous reports of the efficacy of linezolid for the treatment of central nervous system infections caused by multidrug resistant Gram-positive bacteria. To our knowledge, this is the first report of MRSA disseminated cerebritis, a nearly always fatal disease, cured with this oxazolidinone drug. The increase in community acquired MRSA may have some impact on empirical treatment of serious infections caused by this organism.

Sternal wound infection revisited.

Sternal wound infections (SWIs) can be subdivided into two types, superficial or deep, that require different treatments. The clinical diagnosis of superficial SWI is normally easy to perform, whereas the involvement of deep tissues is frequently difficult to detect. Therefore, there is a need for an imaging study that permits the assessment of SWIs and is able to distinguish between superficial and deep SWI. The present work was a prospective study aiming to evaluate the role of technetium-99m hexamethylpropylene amine oxime (99mTc-HMPAO) labelled leucocyte scan in SWI management. Twenty-eight patients with suspected SWIs were included in the study. On the basis of clinical examination they were subdivided into three groups: patients with signs of superficial SWI (group 1), patients with signs of superficial SWI and suspected deep infection (group 2) and patients with suspected deep SWI without superficial involvement (group 3). Ten patients previously submitted to median sternotomy, but without suspected SWI, were also included in the study as a control group (group 4). All patients with suspected SWI had bacteriological examinations of wound secretion, if present. In addition 99mTc-HMPAO labelled leucocyte scan was performed in all patients. The patients of groups 1, 2 and 3 were treated on the basis of the clinical signs and microbiological findings, independently of the scintigraphic results. The patients of group 4 did not receive treatment. The final assessment of infection was based on histological and microbiological findings or on long-term clinical follow-up. Sensitivity, specificity, accuracy and positive and negative predictive values for scintigraphic and non-scintigraphic results were calculated. In the diagnosis of superficial and deep SWI, clinical and microbiological examination (combined) yielded, respectively, a sensitivity of 68.7% and 100%, a specificity of 77.3% and 80.8%, an accuracy of 73.7% and 86.8%, a positive predictive value of 68.7% and 70.6% and a negative predictive value of 77.3% and 100%. The scintigraphic results obtained in superficial SWI yielded a sensitivity of 56.2%, a specificity of 90.9%, an accuracy of 76.3%, a positive predictive value of 81.8% and a negative predictive value of 74.1%, while, by contrast, in deep SWI all of these values were 100%. Therefore, one can conclude that 99mTc-HMPAO labelled leucocyte scan permits accurate diagnosis of deep SWI, solving the main clinical problem in this field. In the present study the categorisation of patients without taking into account 99mTc-HMPAO labelled leucocyte planar scan findings caused a non-negligible number of cases of superficial SWI to be treated as though they were deep SWI. This "overestimation" led to unnecessary surgery, increased and prolonged use of antibiotics with more (higher) toxicity and additional expense.

Oral contraceptives highlight the genotype-specific association between serum phospholipids and activated factor VII.

The present analysis was undertaken to study the effect of oral contraceptive (OC) use on activated factor VII (FVIIa) in subjects characterized by FVII genotypes, with the further aim of evaluating the role of lipids in this pharmacological interaction. In OC users (n=42) and nonusers (n=130) of comparable age, we examined the FVII phenotypic variables (FVII coagulant activity [FVIIc], FVII antigen, and FVIIa), FVII genotypes (the 353R/Q and 5'F7 polymorphisms analyzed in combination; alleles M1/M2 and A1/A2, respectively), and a number of lipid and lipoprotein parameters: serum concentrations of total cholesterol (chol), low density lipoprotein and high density lipoprotein-chol, triglycerides, phospholipids (PhLs), apolipoprotein A1, and lipoprotein(a). PhLs, triglycerides, apolipoprotein A1, chol, FVII antigen, FVIIc, and high density lipoprotein-chol levels were shown to be statistically higher in users than nonusers. FVII levels, particularly those of FVIIa and FVIIc, were much higher in homozygotes for the A1 and M1 alleles (A11 M11), especially in OC users. A strong association was found between PhL and FVIIa: in the multiple regression analysis, women taking OCs who had elevated PhL concentrations also had very high levels of FVIIa, but only if their genotype was A11 M11. These results indicate that the increased FVII levels in OC users depend on the FVII genotype and that high PhL concentrations predict very high levels of FVIIa and FVIIc.

Serum phospholipids are the main environmental determinants of activated factor VII in the most common FVII genotype. European Union Concerted Action "Clotart".

BACKGROUND AND OBJECTIVE: Numerous studies have emphasized the role of triglyceride-rich lipoproteins and of Factor VII (FVII) polymorphisms in determining levels of FVII activity. DESIGN AND METHODS: This study was undertaken to evaluate the role of other lipid fractions and the interaction between lipids and FVII in subjects with recognised genotypes. Volunteer subjects (n=459) from 5 European countries were studied. Blood samples were drawn irrespective of the time of day or fasting status. Levels of FVII activity (FVIIc), activated FVII (FVIIa) and FVII antigen (FVIIAg) were evaluated with reference to a number of lipid parameters (HDL-, LDL- and total cholesterol, triglycerides, phospholipids, lipoprotein(a), and apoliproptein A1). The two most common FVII polymorphisms were analyzed in combination (353R/Q and 5'F7; alleles M1/M2 and A1/A2, respectively). RESULTS: Homozygotes for the A1 and M1 alleles (M11/A11) had significantly higher FVII levels. At multiple regression analysis the strongest predictor of FVIIa and FVIIc was the concentration of phospholipids. This interaction was confined to the A11M11 genotype subjects. INTERPRETATION AND CONCLUSIONS: These data indicate that lipids contribute mainly to FVIIa levels through their phospholipid content, and that the degree of this contribution is strictly dependent on FVII genotypes.

Antiphospholipid-protein antibodies are not an uncommon feature in retinal venous occlusions.

The Primary Antiphospholipid Protein Syndrome (PAPS) is characterised by venous and/or arterial thromboses and recurrent foetal loss, in the presence of the Lupus Anticoagulant (LA), elevated antibodies to cardiolipin (ACA) or both. This investigation evaluates the relation between the PAPS and Retinal Vein Occlusion (RVO). Forty-eight consecutive patients with RVO were screened for ACA and LA. PAPS was present in 16 (33%) of the patients. Our results suggest that testing Antiphospholipid-Protein Antibodies (APA) may be useful in these patients, together with the assessment of other vascular risk factors.

Inhibition of protein S by autoantibodies in patients with acquired protein S deficiency.

This study was undertaken to analyze antibodies to protein S (PS) in patients with an acquired PS deficiency. Plasma from symptomatic patients with acquired (n = 14) or congenital (n = 10) PS deficiency and 10 healthy donors was screened for PS antibodies by immunoblotting and for anti-phospholipid antibodies. PS antibodies (IgG) were detected in five of the patients with acquired PS deficiency. These antibodies belonged to the G1 and G4 immunoglobulin subclasses. IgG fractions from the same 5 patients were shown to inhibit PS activity. The inhibition of PS activity by the 5 IgG fractions was shown to be time- and dose-dependent and was abolished following incubation with purified PS, while no effect was found after absorption with cardiolipin micelles. In addition, anticardiolipin monoclonal or human purified antibodies, failed to exert significant PS inhibition. These findings demonstrate that anti-PS antibodies are able to inhibit PS activity and that this is independent of anti-phospholipid antibodies. Given the clinical features of the patients, these antibodies should be regarded as an expression of the broad autoimmune syndrome involving the phospholipid-binding plasma proteins.

Immunopurified clotting factor concentrates.

Monoclonally purified factor concentrates have been available for hemophilia treatment since the late 1980's. They are biochemically characterized by a high-degree of clotting factor (FVIII or FIX) purification and by the virtual lack of contaminants (immunoglobulins, fibrinogen and fibronectin). The purification procedure sharply reduces the viral load and increases the safety of the concentrate because of the viral inactivation procedures. Viral safety is demonstrated by prospective studies in previously untreated patients as well as by the huge amount of concentrates produced and used so far without reports of untoward side effects. Monoclonal concentrates are also safe in terms of inhibitor production: they do not elicit the appearance of inhibitors to either FVIII or FIX with increased frequency, as shown by data in published prospective studies. Prospective studies have recently demonstrated that the long-term administration of these high purity concentrates does not exert any side effects on the immune system in HIV-positive hemophiliacs. The FIX concentrate is also extremely safe in terms of thrombotic complications: the highly pure FIX does not activate blood coagulation. It has been shown that the monoclonally purified FIX concentrate caused no thrombotic events in high-risk surgical patients who had previously experienced such complications while on Prothrombin Complex Concentrates.

What does one do for the CML patient in relapse after allogeneic bone marrow transplantation?

The management of CML patients with some evidence of disease after BMT depends on the molecular, cytogenetic and hematological findings of relapse. Presently, a number of technical and biological problems do not allow to draw any definitive conclusion on the prognostic significance of Minimal Residual Disease detected by PCR. A positive PCR, particularly if observed late after BMT, leads to increase the frequency of cytogenetic examinations, but a therapeutic intervention is not justified. The criteria to define the cytogenetic relapse are not still established. Therefore it is difficult to interpret the reappearance of Ph-1 chromosome after BMT as disease recurrence invariably progressing towards the hematological phase. However, alpha-Interferon, donor buffy-coat infusion or their association should be considered in the treatment of patients for whom the cytogenetic relapse has been confirmed. The therapeutic approach to patients with hematological relapse is mainly depending on the phase of disease. The single, sequential or combined use of chemotherapy, alpha-IFN, donor buffy-coat infusion and second transplant has been shown to be effective in restoring donor hematopoiesis in several patients who relapsed either in chronic or advanced phase. Prospective, randomized, multicentre trials on CML relapse after BMT should be planned.

In vitro antitumor effect of LAK cells and alpha interferon in combination on tumor cell lines.

In vitro antitumor effects of LAK cells and alpha-2b-Interferon (IFN) either alone or in combination were evaluated on NK resistant (K562) and NK sensitive (Namalwa, Raji) cell lines. Tumor cells were incubated with LAK cells for 4, 8 and 24 hours at a LAK: tumor cell ratio of 1:1, 10:1, 100:1, or with IFN for 48 and 96 h at the concentrations of 100, 1000, 10,000, 100,000 IU/ml. A clonogenic assay was utilised to enumerate residual cells after in vitro treatment. A positive correlation was found between tumor cell killing and effector: target ratio, IFN of 100:1 incubated for 4 h, and 100 IU/ml of IFN incubated for 48 h were further chosen. A synergistic effect was found when IFN was incubated before LAK cells or contemporarily, but not when IFN was incubated after LAK cells. These findings demonstrate that an additive or a synergistic effect in vitro can be obtained by adding the two agents in different sequences and suggest that a potential utility of LAK cells and IFN in vivo should be tested in clinical trials.

High serum IL-2 levels are predictive of prolonged survival in multiple myeloma.

In this study we analysed serum IL-2 levels in 61 patients with multiple myeloma (MM). Patients serum IL-2 levels were significantly higher than normal controls. Moreover, higher serum IL-2 levels were associated with a prolonged actuarial survival. In particular, 87% of the MM patients with IL-2 greater the or equal to 10 U/ml are still alive at 5 years while only 13% of the remaining patients with IL-2 less than 10 U/ml are alive. The multivariate analysis confirmed these data indicating that high serum IL-2 levels are the most useful predictor index of longer survival in MM patients. Furthermore, among the 50 patients in whom serum beta-2-microglobulin (SB2M) determination was available we observed that all patients with serum IL-2 levels greater than or equal to 10 U/ml had SB2M less than 6 micrograms/ml, whereas in patients with serum IL-2 less than 10 U/ml SB2M ranged from 1.3 to 15 micrograms/ml. Using these two parameters we were able to identify three groups of patients with different survival duration. Group A (9 patients) defined by serum IL-2 greater than or equal to 10 U/ml and SB2M less than 6 micrograms/ml in which all patients are alive: group B (26 patients) characterized by serum IL-2 less than 10 U/ml and SB2M less than 6 micrograms/ml in which 24% of patients are alive and group C (15 patients) characterized by serum IL-2 levels less than 10 U/ml and SB2M greater than or equal to 6 micrograms/ml in which the actuarial survival curve drops to 0 at 2.5 years. A statistically significant difference was observed between groups A and B (P less than 0.05), groups A and C (P less than 0.01) and groups B and C (P less than 0.01). These data could reflect the existence of an active T cell control on B cell neoplasia and may suggest the opportunity of a more extensive use of recombinant biological modifiers such as IL-2 in the therapeutic strategy of MM.

Improved methods for the determination of 5-bromo-2-deoxyuridine labelling index in clones and colonies growing in plasma clots.

Bromodeoxyuridine (BrdUrd), an analogue of thymidine is one of the most employed marker to detect the S-phase of the cell cycle. Difficulties are described for the in situ detection of S-phase cells in normal and neoplastic growing clones. In this paper we propose new methods for the detection of BrdUrd in neoplastic clones, growing in plasma clots. In particular, these methods are based on the immunocytochemical staining with horseradish peroxidase and alkaline phosphatase, as well as on a new immunofluorescent streptavidin technique. They allow easy detection of S-phase cells with an inverted light microscope.

In vitro effects of human recombinant alpha-2b interferon on Ph1+ chronic myelogenous leukemia cells maintained in long term marrow cultures: a functional and morphological analysis.

In this study in vitro results obtained with hu rec IFN-alpha 2b on Ph1+ stem cells from patients with chronic myelogenous leukemia in chronic phase (CML in CP) will be discussed: cells were incubated with different IFN concentrations (100, 1000, 10000 IU/ml) for different times (24, 96 hrs, 8, 15, days) and maintained in long term marrow cultures (LTMC); CFU-GM assay, cytochemistry and cytogenetic analyses were performed weekly. A high sensitivity of CML cells to the in vitro treatment with IFN was observed. Cell count in LTMC showed a progressive reduction inversely proportional to time of incubation and concentration of IFN; a marked decrease in colony growth was observed at the end of incubations and during the course of LTMC. Low concentrations of IFN permitted a morphological maturation and the expression of alkaline phosphatase. Cytogenetic analyses showed a marked reduction of mytoses in cultures treated with high concentrations of IFN as result of a combined cytostatic and cytolitic effect; the persistance of 100% Ph1+ cells in LTMC and in CFU-GM colonies might be related, as opposed to in vivo results, to different IFN exposure conditions or might be influenced by other factors.

Anemia in swimmers: fact or fiction? Study of hematologic and iron status in male and female top-level swimmers.

The aim of the project was to examine the hematologic and iron status of a group of top-level male and female swimmers compared with a control group composed of fit, physically active subjects. The following parameters were examined: red blood cells (RBC), hemoglobin concentration (Hb), hematocrit (Hct), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), serum iron (S I), total iron-binding capacity (TIBC), transferrin saturation (Sat), and serum ferritin concentration (S F). The male swimmers had higher values than the control men for RBC (5364 vs. 5163, P less than .01), Hb (15.4 vs 14.8, P less than .01), Hct (49 vs 46.6, P less than .01), TIBC (341 vs 297, P less than .001), and S I (107 vs 86.3, P less than .01). The female swimmers had higher values than the control women for MCV (91.2 vs 88.5, P less than .01), Hb (14 vs 12.8, P less than .01), Hct (44.2 vs 40.4, P less than .001), S F (58.65 vs 42.17, P less than .01), S I (106 vs 75.6, P less than .01), and TIBC (336 vs 278, P less than .001). The differences between men and women were smaller between the men and women of the swimmers group with respect to the men and women of the control group, for Hb: 15.4 vs 14 (P less than .01) and 14.8 vs 12.8 (P less than .001) and S F: 97.24 vs 58.65 (P less than .001) and 99.89 vs 42.17 (P less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Risk of iron overload and 'hemochromatosis allele(s)' in patients on maintenance hemodialysis.

In the present study, we have evaluated the relationship between serum ferritin (SF) levels, 'hemochromatosis allele(s)', blood transfusions and iron parenteral administration in 69 hemodialysis patients. We demonstrated significantly higher SF levels in patients with hemochromatosis allele(s) (HA+) than in patients without hemochromatosis alleles (HA-). In addition, HA+ patients who had received blood transfusions up to 15 months prior to the study had SF levels even higher than those without blood transfusions. On the other hand, HA- patients had normal levels of SF, independent of blood transfusions. After intravenous administration of 1 g iron saccharate, SF levels were significantly higher only in HA+ transfused patients. In conclusion, our study demonstrated that HA+ patients are at a higher risk of iron overload and therefore the use of transfusional and/or parenteral iron should be strictly limited.