Adverse events during treatment of critical limb ischemia with autologous peripheral blood mononuclear cell implant.

AIM: Trials have reported clinical improvement and reduced need for amputation in critical limb ischemia (CLI) patients receiving therapeutic angiogenesis with stem cells. Our objective was to test peripheral stem cell therapy efficacy and safety to gain experiences for further work. METHODS: We included nine CLI patients (mean age 76.7 ±9.7). Stem cells were mobilized to the peripheral blood by administration of G-CSF (Filgrastim) for 4 days, and were collected on day five, when 30 mL of a stem cell suspension was injected into 40 points of the limb. The clinical efficacy was evaluated by assessing pain relief, wound healing and changes in ankle-brachial pressure index (ABI). Local metabolic and inflammatory changes were measured with microdialysis, growth factors and cytokine level determination. Patients were followed for 24 weeks. RESULTS: Four patients experienced some degree of improvement with pain relief and/or improved wound healing and ABI increase. One patient was lost to follow up due to chronic psychiatric illness; one was amputated after two weeks. Two patients had a myocardial infarction (MI), one died. One patient died from a massive mesenteric thrombosis after two weeks and one died from heart failure at week 11. Improved patients showed variable effects in cytokine-, growth factor- and local metabolic response. CONCLUSION: Even with some improvement in four patients, severe complications in four out of nine patients, and two in relation to the bone marrow stimulation, made us terminate the study prematurely. We conclude that with the increased risk and the reduced potential of the treatment, peripheral blood stem cell treatment in the older age group is less appropriate. Metabolic and inflammatory response may be of value to gain insight into mechanisms and possibly to evaluate effects of therapeutic angiogenesis.

Alteration of the colonization pattern of coagulase-negative staphylococci in patients undergoing treatment for hematological malignancy.

The aim was to prospectively describe the colonization pattern of coagulase-negative staphylococci (CoNS) and the relationship between colonizing and invasive CoNS isolates among patients undergoing treatment for hematological malignancy. Fourteen newly diagnosed patients were included with either multiple myeloma or acute leukemia. Patients were repeatedly sampled from nares, throat, axillae, and perineum, and the CoNS isolates obtained were phenotypically characterized together with blood isolates of CoNS using the PhenePlate system (PhP). During the treatment a gradual reduction in the heterogeneity of colonizing CoNS was observed as well as an inter-patient accumulation of phenotypically related and multi-drug-resistant CoNS. These clusters of CoNS persisted for 2-3 months after the end of therapy. Ten positive blood cultures of CoNS were obtained and in the majority of these cases CoNS of the same PhP type were found in superficial cultures collected prior to the blood culture sampling. In conclusion, the study shows that therapy for hematological malignancy is associated with a homogenization of colonizing CoNS isolates and that this acquired flora of CoNS is persistent several months after the end of therapy. Furthermore, the results suggest that the source of bloodstream infections of CoNS in hematological patients is colonizing CoNS of the skin and mucosa.

Glycopeptide resistance in coagulase-negative staphylococci isolated in blood cultures from patients with hematological malignancies during three decades.

The aim of this study was to determine if there was a long-term increase in glycopeptide minimum inhibitory concentration (MIC) values, MIC creep, among bloodstream isolates of Staphylococcus epidermidis and S. haemolyticus isolated from patients with hematological malignancies. We conducted a retrospective single-center study where all positive blood cultures of S. epidermidis (n = 387) and S. haemolyticus (n = 19) isolated from patients with hematological malignancies during three decades, 1980 to 2009, were re-evaluated for the presence of reduced susceptibility to vancomycin and teicoplanin. Three different methods for the detection of reduced susceptibility to glycopeptides were used; standard Etest, macromethod Etest, and glycopeptide resistance detection (GRD) Etest. The median MIC value for vancomycin was 2 mg/L. MIC values for vancomycin and teicoplanin did not show any statistically significant increase during the study period. The presence of heterogeneously glycopeptide-intermediate staphylococci (hGIS) was analyzed among 405 coagulase-negative staphylococci (CoNS) isolates. hGIS were found in 31-45% of the CoNS isolates by the macromethod Etest and in 53-67% by the GRD Etest during the three decades. In conclusion, we did not observe any long-term glycopeptide MIC creep determined by the standard Etest, although a high and increasing proportion of heterogeneous vancomycin resistance was observed.

Continuing high early death rate in acute promyelocytic leukemia: a population-based report from the Swedish Adult Acute Leukemia Registry.

Our knowledge about acute promyelocytic leukemia (APL) patients is mainly based on data from clinical trials, whereas population-based information is scarce. We studied APL patients diagnosed between 1997 and 2006 in the population-based Swedish Adult Acute Leukemia Registry. Of a total of 3897 acute leukemia cases, 3205 (82%) had non-APL acute myeloid leukemia (AML) and 105 (2.7%) had APL. The incidence of APL was 0.145 per 100,000 inhabitants per year. The median age at the time of diagnosis was 54 years; 62% were female and 38% male. Among younger APL patients, female sex predominated (89% of patients <40 years). Of the 105 APL patients, 30 (29%) died within 30 days (that is, early death (ED)) (median 4 days) and 28 (26%) within 14 days from diagnosis. In all, 41% of the EDs were due to hemorrhage; 35% of ED patients never received all-trans-retinoic acid treatment. ED rates increased with age but more clearly with poor performance status. ED was also associated with high white blood cells, lactate dehydrogenase, creatinine, C-reactive protein and low platelet count. Of non-ED patients, 97% achieved complete remission of which 16% subsequently relapsed. In total, 62% are still alive at 6.4 years median follow-up. We conclude that ED rates remain very high in an unselected APL population.

Phenotypic and genotypic characterization of coagulase-negative staphylococci isolated in blood cultures from patients with haematological malignancies.

Coagulase-negative staphylococci are the predominant aetiological agents in bacteraemic patients hospitalized for haematological malignancies. The aim of this study was to determine whether differences exist in the prevalence of icaAB genes and in the phenotypic and/or genotypic pattern between blood isolates of coagulase-negative staphylococci, interpreted as representing true bacteraemia, and contaminant isolates from patients with haematological malignancies. Eighty-two isolates representing true bacteraemia and 47 contaminant isolates were found among 76 patients. The most prevalent species in both groups of patients was Staphylococcus epidermidis (n=103; 80%). Biochemical typing using the Phene Plate system and genotyping using pulsed-field gel electrophoresis showed a tendency towards a more homogeneous pattern among isolates causing true bacteraemia compared with contaminant isolates. Two major genotypic groups of S. epidermidis were found in both the true bacteraemia group and the contaminant group, with concordant pulsotypes found as well. These groups may comprise isolates carrying specific virulence factors, but the prevalence of the icaAB genes did not differ between the true bacteraemia group and the contaminant group. No significant difference was seen between the two study groups regarding clinical symptoms or complications, use of central venous catheter, and levels of absolute neutrophil count or C-reactive protein.

Granulocyte-macrophage colony-stimulating factor to increase efficacy of mitoxantrone, etoposide and cytarabine in previously untreated elderly patients with acute myeloid leukaemia: a Swedish multicentre randomized trial.

A total of 110 patients, aged 64 years or over, with de novo acute myeloid leukaemia (AML) and white blood cell counts <50 x 109/l were treated with 3 d of cytarabine 1 g/m2 twice daily, mitoxantrone 12 mg/m2 and etoposide 200 mg/m2, randomized with or without the addition of granulocyte-macrophage colony-stimulating factor (GM-CSF) 200 microg/m2. The primary aim was to evaluate the effect of GM-CSF on the remission rate. Secondary aims included comparison of duration of remission, survival and infectious complications and the impact of maintenance therapy with thioguanine. Complete remission (CR) was achieved by 64% of patients without GM-CSF, and by 65% of patients who received GM-CSF, the median remission duration was 13 vs. 6 months, the median overall survival (OS) was 14 vs. 9 months, the mean time to neutrophil recovery was 25 vs. 17 d (P = 0.03) and the number of positive blood cultures was 46 vs. 39 (P = 0.05) respectively. The impact of thioguanine remains unanswered since only 30 patients remained in CR after consolidation therapy. We conclude that induction therapy is feasible with acceptable toxicity in elderly patients with AML, albeit with a high relapse rate and short OS. GM-CSF prior to, and in combination with, induction treatment reduced the time to neutrophil recovery and the number of neutropenic septicaemia cases but did not improve the OS of AML in the elderly.

No benefit from adding GM-CSF to induction chemotherapy in transforming myelodysplastic syndromes: better outcome in patients with less proliferative disease.

In this prospective randomized multicenter trial 93 patients, median age 72 years, with RAEB-t (n=25) and myelodysplastic syndrome (MDS)-AML (n=68) were allocated to a standard induction chemotherapy regimen (TAD 2+7) with or without addition of granulocyte-macrophage-CSF (GM-CSF). The overall complete remission (CR) rate was 43% with no difference between the arms. Median survival times for all patients, CR patients, and non-CR patients were 280, 550, and 100 days, respectively, with no difference between the arms. Response rates were significantly better in patients with serum lactate dehydrogenase (S-LDH) levels

Human cytomegalovirus, human herpesvirus-6 and human herpesvirus-7 in neutropenic patients with fever of unknown origin.

OBJECTIVE: To investigate the appearance of cytomegalovirus (CMV) DNA, human herpesvirus-6 (HHV-6) DNA and human herpesvirus-7 (HHV-7) DNA in plasma as a sign of reactivation and possible causes of fever of unknown origin (FUO) during neutropenia. METHODS: From 134 patients with febrile neutropenia following cytotoxic chemotherapy during the years 1996-2000, 20 severely neutropenic patients (granulocyte count < 0.1 x 109/L) were selected. Ten were patients with bacteremia and ten were patients with FUO. Five samples from each patient were selected at the start of chemotherapy, at the time of blood culture and fever, after 24 and 48 hours of fever, and, finally, after two to three days without fever. Virus DNA was detected by real-time quantitative and nested polymerase chain reaction (PCR). RESULTS: CMV-DNA was detected in two out of ten FUO-patients in all samples drawn during fever. From another FUO and during two bacteremia episodes, CMV-DNA was detected after 48 hours of fever. DNA from HHV-6 and HHV-7 was not detected in any of the 20 febrile episodes. CONCLUSIONS: HHV-6 and HHV-7 as a possible explanation for FUO in severely neutropenic patients treated with cytotoxic chemotherapy seems not be very likely. However, CMV was identified in 5/20 patients and the febrile episodes in the two FUO-patients with constant DNA-emia may have been caused by a reactivation of CMV. This implies that CMV infection can be expected not only in transplant patients but also in chemotherapy-treated neutropenic patients.

Long-term follow-up of patients >or=60 yr old with acute myeloid leukaemia treated with intensive chemotherapy.

It is still controversial how to treat elderly patients with acute myeloid leukaemia (AML), and results have been poor with most regimens. We report the long-term results of a randomised study performed by the Leukaemia Group of Middle Sweden during 1984-88 comparing two intensive chemotherapeutic drug combinations. Ninety patients >or=60-yr old with untreated AML were randomly allocated to treatment with daunorubicin, cytosine arabinoside (ara-C), and thioguanine (TAD) (43 patients) or a combination in which aclarubicin was substituted for daunorubicin (TAA) (47 patients). Forty-four patients (49%) entered complete remission (CR), 22/43 (51%) in the TAD group and 22/47 (47%) in the TAA group (ns). The CR rate in patients 70 yr 14/48 (29%) (P<0.0001). Early death within 30 d after treatment initiation was more often seen in patients >70 yr than in patients or=10 yr after inclusion of the last patient, 5/90 patients (one in the TAD group and four in the TAA group, respectively) were still alive, four in continuous complete remission and one in second complete remission. Thus, both treatment regimens appear to have similar efficacy, with a relatively high complete remission rate, and a reasonable survival as compared to other studies including some long-term survivors. However, early deaths are still numerous, particularly in patients above 70 yr of age, and the relapse rate is substantial.

Activation of granulocytes in patients treated with chemotherapy.

It is well known that patients with granulocytopenia due to chemotherapy are susceptible to life-threatening infections. To determine whether or not granulocyte function is also impaired by chemotherapy, respiratory burst, CD11b and CD18 expression were analysed by flow cytometry in granulocytes from 10 patients with haematological malignancies: before and after the commencement of high-dose chemotherapy and in the recovery phase. As a comparison, the same granulocytic functions were analysed in patients treated with low-dose hydroxyurea and in healthy volunteers. The granulocytes were activated by Staphylococcus aureus and Staphylococcus epidermidis. A decreased ability to mobilize CD18 in the recovery phase was seen, but the significance of this finding must be evaluated carefully owing to the small patient number.

Interactions between P-glycoprotein and drugs used in the supportive care of acute myeloid leukemia patients.

Multidrug resistance due to overexpression of P-glycoprotein (Pgp) leads to reduced intracellular drug accumulation and makes the cells resistant to chemotherapy. In this study we focused on how drugs used in the supportive care of acute myeloid leukemia (AML) patients interfere with Pgp. The effect on intracellular accumulation of the fluorescent dye Rhodamine 123 (Rh 123) was studied in the human promyelocytic leukemia cell line HL-60 and two anthracycline resistant, Pgp expressing, sublines. Each drug was used at two different concentrations: plasma peak concentration and half the plasma peak concentration. Drugs which increased the Rh 123 uptake by > 10% were included in the second part of the study where the cytotoxic effect was tested in combination with daunorubicin. In the Rhodamine assay none of the tested drugs had any significant effect on the Rh 123 efflux in the resistant cell lines. Amphotericin B, cefuroxime, erythromycin and dixyrazin had minor effects on Rh 123 uptake but showed a significant additive effect to the toxicity of daunorubicin suggesting other mechanisms of action than reversal of Pgp. In conclusion this in vitro model where Rh 123 uptake was studied in an anthracycline resistant leukemia cell line could not demonstrate any significant interactions with Pgp for the tested drugs.

Expression of topoisomerase IIalpha in the G0/G1 cell cycle phase of fresh leukemic cells.

Topoisomerase IIalpha (topo IIalpha) is the target enzyme for several antineoplastic drugs. Correlation between low expression of topo IIalpha and drug resistance has been shown in vitro, but there is limited evidence of a correlation to initial response to treatment or to overall prognosis. Normal cells express topo IIalpha in S/G2/M phase of the cell cycle but not in G0/G1 phase. However, some data suggest that topo IIalpha could be expressed in G0/G1 phase in malignant cells. We have investigated the expression of topo IIalpha in leukemic cells from 25 patients with acute leukemia by flow cytometry, separating cells of different cell cycle phases. We demonstrated that 9/25 samples showed >50% positive cells in G0/G1, and another five samples showed >20%. This finding could possibly provide an explanation to previous difficulties in correlating topo IIalpha expression with clinical outcome. Six of eight patients, where >20% of the cells in G0/G1 were positive for topo IIalpha, entered CR, compared to one of five patients with <20% topo IIalpha positive cells in G0/G1. We suggest that topo IIalpha expression in G0/G1 in leukemic cells may be of predictive value for clinical response to cytostatic drugs.

[Prevention and early diagnosis of cancer. What do we know? What do we think? Reports from the Lakardagarna in Orebro]. / Prevention och tidigdiagnostik av cancer. Vad vet vi? Vad tror vi? Vad gör vi? Referat från Läkardagarna i Orebro.

Läkardagarna (physician days) in Orebro is an annual course arranged by the Orebro Society of Medicine in collaboration with The Swedish Society of Medicine. In the year 2000 the title was "Prevention and early diagnosis of cancer. What do we know? What do we believe? What do we do?" With general practitioners as the target audience, the course covered basic biological science, risk factors, screening, ethical questions and the general practitioner's dilemma. This article reviews four selected contributions: 1) What is cancer? 2) Possible importance of the fetal stage for later risk of cancer; 3) Infections as a cause of cancer; and 4) Screening for cancer.

Adjustment of incidence rates after an estimate of completeness and accuracy in registration of acute leukemias in a Swedish population.

Earlier studies have revealed undernotification of hematological malignancies in Swedish and other Cancer Registries. We present epidemiological data on AML, ALL and unspecified AL in adults diagnosed 1987-1992 in a well-defined population. Blast crises of CML were excluded. The Swedish Cancer Registry and Cause of Death Registry were compared and patient records reviewed for validation. When available, listings of pathology bone marrow reports and inpatient discharge diagnoses were utilized for casefinding. 260 cases of acute leukemias could be verified in a population of 663,135 adults, corresponding to a yearly incidence of 6.5/100,000. The median age of the patients was 69.2 years. 214 cases were AML, 38 ALL and eight unspecified AL. Undernotification in the Cancer Registry was found to be 15.4%, greater for AML and unspecified AL than for ALL. In addition the coding was not uniform, resulting in an incidence rate in adults of 5.3/100,000 for the Cancer Registry which is 18.5% lower than that of our study. A significant survival advantage was seen for notified patients. Combination of the Cancer Registry and Cause of Death Registry gave acceptable coverage, omitting only four patients. As the incidence of acute leukemias in our study is comparatively high, we hypothesize that underestimation of incidence and overestimation of survival are general problems for cancer registries.

Treatment, long-term outcome and prognostic variables in 214 unselected AML patients in Sweden.

With the aim of describing an unselected series of acute myeloid leukaemias (AML) in adults, patients diagnosed 1987-1992 in the Orebro region of central Sweden were reviewed by investigating hospital records. By utilizing: (1) The Swedish Cancer Registry, (2) The Cause of Death Registry, (3) listings of pathology bone marrow reports and (4) listings of inpatient discharge diagnoses, we attempted to find all patients. Among secondary AML, only blast-crises of CML were excluded. A total of 214 cases of AML with a median age of 69.5 years were verified corresponding to a mean yearly incidence in adults of 5.4/100 000. Of all patients, 56% had received 'high-dose' induction treatment, 28% 'low-dose' treatment and 16% no cytostatic treatment. Median survival for all patients was 5.8 months and the probability of survival at 5 years was 9.3%. The 120 'high-dose' treated patients had a total CR rate of 67%, median CR duration 10.1 months and median survival 11.4 months. Age, LDH and kidney function were found to be independent prognostic variables for survival. The inclusion of patients unreferred from district hospitals makes this study unique as an example of unselected AML.

P-Glycoprotein inhibitor valspodar (PSC 833) increases the intracellular concentrations of daunorubicin in vivo in patients with P-glycoprotein-positive acute myeloid leukemia.

PURPOSE: The aim of the present study was to evaluate the effect of the cyclosporine derivative valspodar (PSC 833; Amdray, Novartis Pharma, Basel, Switzerland) on the concentration of daunorubicin (dnr) in leukemic blast cells in vivo during treatment. PATIENTS AND METHODS: Ten patients with acute myeloid leukemia (AML) were included. Leukemic cells from seven of the patients were P-glycoprotein (Pgp)-positive. dnr 100 mg/m(2) was given as a continuous infusion over 72 hours. After 24 hours, a loading dose of valspodar was given, followed by a 36-hour infusion of 10 mg/kg per 24 hours. Blood samples were drawn at regular intervals, and concentrations of dnr and its main metabolite, daunorubicinol, in plasma and isolated leukemic cells were determined by high-pressure liquid chromatography. RESULTS: The mean dnr concentrations in leukemic cells 24 hours after the start of infusion (before valspodar) were 18.8 micromol/L in Pgp-negative samples and 13.5 micromol/L in Pgp-positive samples. After 8 hours of valspodar infusion, these values were 25.8 and 24.0 micromol/L, respectively. The effect of valspodar was evaluated from the ratio of the area under the curve (AUC) for dnr concentration versus time in leukemic cells to the AUC for dnr concentration against time in the plasma. For the seven patients with Pgp-positive leukemia, the mean ratio increased by 52%, from 545 on day 1 to 830 on day 2 (P<.05) when valspodar was given. In the three patients with Pgp-negative leukemia, no significant difference was observed. CONCLUSION: These results strongly suggest that valspodar, by interacting with Pgp, can increase the cellular uptake of dnr in leukemic blasts in vivo.

In vitro chemosensitivity testing in acute non lymphocytic leukemia using the bioluminescence ATP assay.

The ATP assay is a short term in vitro chemosensitivity assay where the amount of viable cells are determined by their content of ATP. The aim of the study was to compare the in vitro results of six cytostatic drugs to the clinical outcome in 83 acute non-lymphocytic leukemia (ANLL) patients. The secondary ANLL at diagnosis showed an in vitro resistance to daunorubicin that was significantly higher compared to de novo ANLL at diagnosis (P<0.003). De novo ANLL at diagnosis that achieved complete remission (CR) were significantly more sensitive to daunorubicin compared to those who didn't achieve CR (P<0.05). There was an vitro correlation between topoisomerase II active drugs but not between these drugs and ara-C. In vitro ara-C sensitivity (< or = the median of the de novo ANLL at diagnosis) was correlated to poor overall survival (P = 0.02). In vitro sensitivity to daunorubicin and mitoxantrone was associated with prolonged disease free survival (P = 0.03 and P = 0.04). We conclude that despite significant correlation to clinical parameters for daunorubicin and mitoxantrone the predictive value of the ATP assay in this material was insufficient for directing therapy.

Increased incidence of bacteraemia due to viridans streptococci in an unselected population of patients with acute myeloid leukaemia.

The aetiology, clinical characteristics and outcome of bacteraemia in patients with acute myeloid leukaemia were studied. All positive blood cultures collected at a haematological ward during 2 7-y periods were evaluated. Altogether, 274 episodes of bacteraemia in 152 patients were recorded, 80 episodes during 1980-86 and 194 during 1990-96. During the 2 periods, trimethoprim-sulfamethoxazol in combination with amikacin was the first-line empirical therapy in patients with neutropaenia and fever. In 1990, antimicrobial prophylaxis with ciprofloxacin and fluconazole was introduced. The incidence of bacteraemia due to viridans streptococci or coagulase-negative staphylococci increased from the first period to the second, whereas the incidence of Enterobacteriaceae decreased. In granulocytopaenic patients during 1990-96, viridans streptococci accounted for 21% of the isolates and in patients treated prophylactically with fluoroquinolone, viridans streptococci accounted for 31%. All viridans streptococci were sensitive to penicillin. At the time of the positive blood cultures, the patients of the second period were granulocytopaenic in 83% of the episodes. The mortality related to septicaemia during the later period was 13% and only 1 of 33 (3%) of the patients with viridans streptococci died. Eight patients (9%) died in relation to septicaemia following curative antileukaemic therapy.

[LGL syndrome can imitate Felty's syndrome. The diagnosis can be established by a simple test]. / LGL-syndrom kan imitera Feltys syndrom. Enkel utredning kan fastställa diagnosen.

The article consists in a discussion of neutropenia caused by large granular lymphocytes (LGLs), illustrated by a review of the literature and case reports of five patients with LGL syndrome and one patient whose clinical characteristics were more consistent with classic Felty's syndrome. Recent years have witnessed advances in our knowledge of clonal expansions of suppressor-type T-cells and their capacity to induce neutropenia. The phenotypes of such cells are CD3+, CD8+ and CD57+. The syndrome is often seen in patients with rheumatoid arthritis, and if they also manifest splenomegaly it may be confused with Felty's syndrome. Appropriate evaluation and treatment of the condition are also discussed, and an attempt made to clarify the confusing terminology.

Kinetics of peripheral blood stem cell harvests during a single apheresis.

BACKGROUND: The enumeration of CD34+ cells in the peripheral blood of patients before leukapheresis is commonly used to predict the outcome of stem cell harvests. The concept that an increased number of transplanted cells gives faster marrow reconstitution triggers an interest in investigating the kinetics of peripheral blood stem cells during leukapheresis. The aim of this study was to investigate the issue of recruitment of hematopoietic progenitor cells during a single leukapheresis. STUDY DESIGN AND METHODS: Nine leukapheresis procedures (in 8 patients) were investigated. In each case, 3 blood volumes were processed. Samples from peripheral blood, the collection line of apheresis equipment, and the collected component were obtained after each blood volume was processed. The enumeration of CD34+ cells was performed, and the total number of progenitors, as a sum of the number of cells in the peripheral blood and the number of cells in the collected component, was calculated. RESULTS: A mean of 13.3 L of blood was processed, and a component with a mean volume of 424 mL and a mean of 10.1 x 10(6) CD34+ cells per kg of body weight was collected. White cell and mononuclear cell counts in peripheral blood declined concomitantly during the procedures. The calculated total number of cells--that is, the sum of the number of cells in the collected component and the number of cells in the peripheral blood--showed a concomitant, but not equal, rise in polymorphonuclear cells, mononuclear cells, and CD34+ cells during the leukapheresis. This apparent mobilization of progenitors into the peripheral blood did not correlate with the slightly increased number of polymorphonuclear cells or with the more pronounced increase in mononuclear cells. CONCLUSION: There is a substantial recruitment of progenitor cells during a single leukapheresis.