Neuropsychological assesment of psychogeriatric patients with limited education.

Traditional published norms for neuropsychological tests that do not consider demographic effects can lead to spuriously high false positive rates among low-educated elderly individuals. This problem may be compounded when trying to identify dementia in psychogeriatric patients whose cognitive functioning is also compromised by psychiatric illness. This study investigated the clinical utility of low education neuropsychological test norms to discriminate amongst demented and nondemented psychogeriatric inpatients and healthy community elderly with limited education. Results indicated that the Mattis Dementia Rating Scale (MDRS), the Fuld Object Memory Evaluation (FOME), the Mini-Mental State Examination (MMSE), and a Clock drawing task had high discriminability in differentiating the three groups. Application of demographically corrected norms has important implications for diagnosis and treatment planning, especially when neuropsychological status is complicated by psychiatric illness.

Diphtheria toxin fused to granulocyte-macrophage colony-stimulating factor is toxic to blasts from patients with juvenile myelomonocytic leukemia and chronic myelomonocytic leukemia.

We have previously demonstrated that human granulocyte-macrophage colony-stimulating factor fused to a truncated diphtheria toxin (DT388-GM-CSF) is toxic to patient acute myeloid leukemia progenitors bearing the GM-CSF receptor, but not normal marrow progenitors. We now report that exposure of mononuclear cells from five of seven (71%) juvenile myelomonocytic leukemia (JMML) patients and from 12 of 20 (60%) adult chronic myelomonocytic leukemia (CMML) patients to 10(-9) mol/L DT388-GM-CSF for 48 hours in culture reduces the number of cells capable of forming colonies in semisolid medium (colony-forming units-leukemia) 10-fold to 300-fold (1 to 2.5 log decrease). In contrast, normal myeloid progenitors (colony-forming unit-granulocyte-macrophage) from six different donors treated and assayed under identical conditions were consistently insensitive to the same fusion toxin even when treated as highly purified CD34(+) cells. The leukemic progenitors from the two other JMML patients showed intermediate sensitivity to DT388-GM-CSF and the leukemic progenitors from eight of the 20 (40%) CMML patients were not different from normal progenitors. Parallel measurements of the number and affinity of GM-CSF receptors on cells from the same samples showed no consistent differences between JMML, CMML, and normal light density or CD34(+) bone marrow cells. The increased sensitivity of leukemic progenitors from all JMML progenitors and some CMML patients to the fusion toxin is therefore not likely to be explained by an increased density of GM-CSF receptors on these cells. We also examined the DT388-GM-CSF sensitivity of two murine cell lines transfected with cDNAs encoding varying portions of the human GM-CSF receptor and/or beta chains. These studies showed that high-affinity ligand binding was sufficient for DT388-GM-CSF-induced toxicity, as this could occur even in the absence of functional signal transduction and that the background of the host cell had a major influence on the degree to which this decreased the toxicity of DT388-GM-CSF. The selective sensitivity to DT388-GM-CSF of leukemic progenitors from a majority of JMML and CMML patients suggests that this agent could have therapeutic potential for some patients with these diseases.

The development of an enzyme immunometric assay for LH and the effects of the methods on the immunoreactivity of the conjugates.

Using an affinity purified sheep anti-human luteinizing hormone IgG-horseradish peroxidase conjugate (sheep anti-hLH IgG-HRP) and rabbit anti-human luteinizing hormone antiserum (rabbit anti-hLH) directed against different antigenic determinants, a solid-phase "sandwich" enzyme immunometric assay (EIMA) for human luteinizing hormone (hLH) was developed. The assay was validated and compared with a liquid phase "two site" immunoradiometric assay (IRMA) for hLH which uses same two antibodies. The sheep anti-hLH IgG, which had been affinity purified by eluting at pH 3.5 from a hLH-sepharose 4 B column, was labelled with 125I. The IRMA is based on simultaneous addition of two antibodies to standards and samples. After overnight incubation, separation was achieved by addition of Sheep anti-Rabbit Fc (SARFc) antiserum. In EIMA; partially denaturated (at pH 2.5) Sheep anti-Rabbit FcIgG (SARFcIgG) coated polystyrene tubes or microtitre plates were employed as solid-phase second antibody. The substrate was N,N'-o-phenylene diamine (2 mg/ml) and H2O2 (O.02%). Two methods, modified NaIO4 and 4-(N-maleimido methyl)-cyclohexane-1-carboxylic acid N-hydroxy succinimide ester (SMCC), were employed in the preparation of sheep anti-hLH IgG-HRP conjugate. The immunoreactivity and peroxidase activity of conjugate prepared with NaIO4 method was impared to various extends. Both EIMA and IRMA had good specificity, were not susceptible to interference from serum components and exhibited very low non-specific binding. The values determined by EIMA were independent of the serum volume employed. Standard added to serum samples was accurately determined and the results obtained from the analysis of serum samples correlated closely with those obtained by IRMA.

Malignant progenitors from patients with acute myelogenous leukemia are sensitive to a diphtheria toxin-granulocyte-macrophage colony-stimulating factor fusion protein.

We have previously demonstrated that human granulocyte-macrophage colony-stimulating factor (GM-CSF) fused to a truncated diphtheria toxin (DT388-GMCSF) kills acute myelogenous leukemia (AML) cell lines bearing the GM-CSF receptor. We now report that exposure of malignant cells from 50 different patients with AML for 48 hours in culture to DT388-GMCSF reduces by a median of 1.6 logs (range, 0 to 3.7 logs) the number of leukemic cells capable of forming colonies in semisolid media (leukemic colony-forming cells [CFU-L]) with a median IC50 of 3 x 10(-12) mol/L (range, 5 to >4,000 x 10(-12) mol/L). Furthermore, the cell kill is dependent on the presence of high-affinity GM-CSF receptors on leukemic blasts, because CFU-L from 27 of 28 AML samples expressing > or = 35 GM-CSF receptors per cell were inhibited by the toxin, whereas the colony growth from all 4 leukemic samples (2 AML, 1 acute lymphoblastic leukemia [ALL], and 1 prolymphocytic leukemia [PLL]) that had less than 35 receptors per cell was unaffected by the drug. Sensitivity of CFU-L to DT388-GMCSF was seen regardless of the clinical responsiveness of the patient's leukemia to standard chemotherapy agents. In contrast, clonogenic cells from normal bone marrow formed colonies at near control numbers after exposure to much higher toxin concentrations (4 x 10(-9) mol/L) than those required to kill CFU-L from most patients. Thus, leukemic progenitors isolated directly from the peripheral blood of most AML patients show the same sensitivity to DT388-GMCSF as previously demonstrated for AML cell lines. Under the same conditions of exposure, normal hematopoietic progenitors are relatively unaffected by DT388-GMCSF, suggesting its potential as a therapeutic agent in AML.

Cell-specific modulation of drug resistance in acute myeloid leukemic blasts by diphtheria fusion toxin, DT388-GMCSF.

Radiochemotherapy-resistant blasts commonly cause treatment failure in acute myeloid leukemia (AML), and their resistance is due, in part, to overexpression of multidrug resistance (mdr) proteins. We reasoned that targeted delivery of protein synthesis inactivating toxins to leukemic blasts would reduce the cellular concentrations of relatively short half-life resistance proteins and sensitize the cells to cytotoxic drugs. To test this hypothesis, we employed human granulocyte-macrophage colony-stimulating factor fused to truncated diphtheria toxin (DT388-GMCSF). The human AML cell line HL60 and its vincristine-resistant sublines, HL60Vinc and HL60VCR, were incubated in vitro for 24 h with varying concentrations of toxin. Doxorubicin was added for an additional 24 h, and cell cytotoxicity was assayed by thymidine incorporation and colony formation in semisolid medium. DT388-GMCSF sensitized HL60Vinc and HL60VCR but not HL60 to doxorubicin. Combination indices for three log cell kill varied from 0.2 to 0.3. In contrast, pretreatment with doxorubicin followed by toxins failed to show synergy. At least in the case of the vincristine-resistant cell lines, modulation of drug resistance correlated with reduction in membrane P-glycoprotein concentrations based on immunoblots with C219 antibody, flow cytometry with MRK16 antibody, and cell uptake of doxorubicin. These observations suggest clinical trials of combination therapy may be warranted in patients with refractory AML. Further, targeted toxins may represent a novel class of cell-specific modulators of drug resistance for a number of malignancies.

Hearing disorder and cognitive function of individuals with Down syndrome.

The relationship between hearing disorder and performance on intelligence tests among 28 children and young adults with Down syndrome was investigated. Intellectual and audiological assessments were obtained and evaluated in a multiple regression analysis. Performance on intelligence tests by individuals with abnormal tympanograms was inferior to that of individuals with normal tympanograms. Hearing sensitivity measures were uncorrelated. Findings suggest the need for an awareness of the potential impact of middle ear disorder when assessing intellectual functioning and the importance of otological care for infants and young children with Down syndrome.

Fetal vesicoureteral reflux.

Intrauterine fetal vesicoureteral reflux has been demonstrated in a 25-week fetus. A voiding cystourethrogram when the patient was 1 year old showed persistence of the bilateral reflux. No urinary tract infectious have been documented. A survey of other physicians performing fetal transfusions indicates that fetal cystograms are infrequently obtained and that vesicoureteral reflux has been observed by ourselves and one other contributing physician. The incidence of reflux in fetal cystograms reviewed appears to be higher than would be expected when compared to normal premature babies, newborns, infants and children. This procedure provides an unusual opportunity to document intrauterine fetal vesicoureteral reflux and later obtain followup cystourethrograms in these children to determine the resolution or progression of this urinary tract abormality.

Leukemia in pregnancy.

For clinical consideration, leukemia in association with pregnancy can be divided into acute and chronic forms. Maternal mortality in acute leukemia is 100%, and in the chronic form it is 36.5%. Perinatal mortality is 34-36% in acute leukemia and 16.2% in chronic leukemia. The incidence of postpartum hemorrhage is 15-19%; however, in a recent study it was 83%. Chemotherapy and irradiation usually do not produce gross abnormalities of the fetus if given only during the second and third trimesters; however, the subsurface genetic damage that may be done and new mutants that may be produced are unknown. Caution must be used in radiation therapy because of possible late carcinogenic effects and increase in subsequent mortality and leukemia in infants exposed to radiation in utero. Transmission of leukemia from the mother to the fetus is rare. The main objective in management is to maintain the disease in remission long enough to obtain an infant that will survive outside of the uterine environment. The liberalization of abortion, improved methods of birth control, and the improvement in survival rates with new drug combinations and immunotherapy may make the association of leukemia and pregnancy even more rare.