Use of copeptin and high-sensitive cardiac troponin T for diagnosis and prognosis in patients with diabetes mellitus and suspected acute myocardial infarction.

BACKGROUND: Diabetes is a major risk factor for acute myocardial infarction (AMI). Assessment of diabetic patients is challenging due to an often atypical presentation of symptoms. We aimed to evaluate the two novel biomarkers copeptin and high-sensitive cardiac troponin (hs-TnT) for the improvement of early diagnosis and risk-stratification in patients with diabetes and suspected AMI. METHODS: In this prospective international multicenter study we evaluated 379 patients with diabetes in a cohort of 1991 patients presenting with symptoms suggestive of AMI. The measurement of biomarkers was performed at presentation. RESULTS: Among the 379 diabetic patients, 32.7% had AMI, and in the 1621 patients without diabetes, 18.8% had AMI. The additional use of copeptin improved the diagnostic accuracy provided by conventional troponin alone (AUC 0.86 vs. 0.79, p=0.004). During a median follow-up of 814 days, 49 (13.1%) diabetic patients died. Cumulative 2-year survival rate for patients with copeptin levels below 9 pmol/l was 96.6% compared to 82.8% in patients above that level (p<0.001). The same was observed for hs-TnT with a cutoff level of 14 ng/l (97.7% vs. 82.0%, p<0.001) respective of cTnT with a cutoff level of 10 ng/l (93.5% vs. 75.6%, p<0.001). In multivariate Cox analysis, copeptin, hs-TnT and cTnT were strong and independent predictors of 24-month-mortality. Using the dual marker strategy (copeptin and troponin) identified two groups of high-risk patients where 22.5% of the group with hs-cTnT and copeptin above the cutoff and 28.6% with cTnT and copeptin above the cutoff died. CONCLUSION: In diabetic patients, copeptin only slightly improves the early diagnosis of AMI provided by hs-cTnT. However, both markers (copeptin and troponin) predict long-term mortality accurately and independently of each other.

In vitro toxicity of taxol based anticancer drug combinations on human hemopoietic progenitors.

The sequence dependency of the interaction of taxol with other anticancer drugs is of clinical importance, and may be due to pharmacokinetic changes and/or to inherent differences in the sensitivity of target normal or cancer cells. This study presents results on the in vitro interaction of taxol with doxorubicin, cisplatin, etoposide and vinorelbine in alternate sequences on human hemopoietic progenitors (CFU-GM). Peripheral blood mononuclear non adherent cells were exposed to IC50 of Taxol for 24 hours and then, for 1 hour to IC50 of each of the other drugs. In a second set of experiments the reverse sequence was applied. The cell suspension was subsequently cultured to assay the growth of CFU-GM. A strong sequence dependency characterizes the combination taxol-vinorelbine, while for the other combinations the order of sequence appears to have little impact on in vitro toxicity on CFU-GM. Comparing results on CFU-GM with that obtained in vitro with the same combination sequences on cancer cell lines some remarkable differences show up. Studies on a normal human myeloid line may therefore have a place in preclinical evaluation of sequence of anticancer drug combinations.

Splenectomy induced complete remission in a patient with multicentric Castleman's disease and autoimmune hemolytic anemia.

Castleman's disease (CD) is a rare disorder of the lymphoid tissue in which the clinical manifestations often mimic a malignant lymphoma. Despite the absence of monoclonality of the lymphoid proliferation, the multicentric variant of the disease (MCD) is characterized by severe symptoms and poor prognosis. Etiologic, pathogenetic, and therapeutic aspects of MCD are still uncertain. We report the case of a 57-year-old patient affected by MCD complicated by severe immunohemolytic anemia. Whereas the clinical and laboratory response to steroids and chemotherapeutic agents was only partial, splenectomy induced a complete remission of hemolysis and disappearance of the constitutional symptoms and of all generalized lymphadenopathies.

Hypothalamic-pituitary-adrenocortical axis function in premenopausal women with rheumatoid arthritis not treated with glucocorticoids.

OBJECTIVE: To assess hypothalamic-pituitary-adrenocortical axis function in patients with rheumatoid arthritis (RA) not previously treated with glucocorticoids in relation to their inflammatory condition and in comparison to healthy controls. METHODS: We evaluated, in 10 premenopausal patients with RA and 7 age matched controls, plasma dehydroepiandrosterone (DHEA), its sulfate (DHEAS), and cortisol concentrations, together with inflammatory cytokine levels [interleukin 6 (IL-6) and IL-12], both in basal conditions and after stimulation with ovine corticotropin releasing hormone (oCRH) and with low dose intravenous (5 microg) adrenocorticotropic hormone (ACTH). RESULTS: DHEA and DHEAS basal concentrations were found to be significantly lower (p<0.05) in premenopausal patients with RA than in controls. As expected, significantly higher basal levels of IL-6 and IL-12 (p<0.05) were found in patients with RA. After the low dose ACTH testing, the DHEA area under the curve value was found to be significantly lower (p<0.01) in patients than controls. Similar results, but without statistical significance, were observed after oCRH stimulation. DHEA levels at basal time showed a significant negative correlation with the erythrocyte sedimentation rate and platelet count, as well as with the Steinbrocker class of the disease (p<0.05). Normal plasma cortisol levels during oCRH and ACTH testing were found in patients with RA in spite of their inflammatory condition. After ACTH testing, IL-6 levels decreased significantly (p<0.05), whereas IL-12 levels were unchanged. No significant changes in IL-6 and IL-12 levels were found after oCRH testing. CONCLUSION: The abnormal androgen concentrations observed during testing in patients with RA might support the implication of adrenal androgens in the immune/inflammatory cytokine mediated mechanisms involved in the pathophysiology and clinical aspects of RA.

In vitro toxicity of A 3'-azido-3'-deoxythymidine and hydroxyurea combination on normal myeloid progenitors.

Hydroxyurea (HU) appears to increase 3'-azido-3'-deoxythymidine (AZT) antiretroviral activity and cytotoxicity by inhibiting thymidilate synthesis. The combination of AZT and HU may therefore be of clinical usefulness. We evaluated the in vitro hemotoxicities of different combinations of AZT and HU in comparison with the hemotoxicities exerted by either of the two drugs alone. Peripheral blood granulocyte macrophage committed progenitors (CFU-GM) of healthy donors were selected as targets of hemotoxicity. Both AZT and HU separately had a dose-dependent inhibitory effect on the in vitro growth of normal circulating CFU-GM. The combination of the two drugs induced a statistically significant synergistic cytotoxicity. In fact, addition of HU induced a remarkable reduction of AZT ID50. Thus, future clinical application of AZT, HU combination should take into account the greater hemosuppressive action of the combination in respect to that observed following administration of either drug alone.

Toxicity on human hemopoietic progenitors of 2'-2'-difluoro-2'deoxycytidine (gemcitabine).

This study presents results on 2'-2'-difluoro-2'deoxycytidine's (dFdC: gemcitabine) in vitro toxicity on peripheral blood CFU-GM and BFU-E obtained from healthy volunteers. Peripheral blood mononucleated non-adherent cells were cultured according to standard methods with continuous exposure (13 days) to dFdC (4,40 and 400 pmol/L) or following 1 hour's, incubation with increasing drug concentrations (1, 10, 100 mumol/L). The results indicate that dFdC has a marked dose-dependent inhibitory effect on the in vitro growth of peripheral blood hemopoietic progenitors., No significant differences were observed for the growth inhibition induced on CFU-GM and BFU-E. Continuous exposure to dFdC gave an IC50 of 4 pmol/L for both CFU-GM and BFU-E. In four chemotherapy naive patients affected by tumors of different type treated with three standard courses of dFdC the variations in the peripheral blood of hemopoietic progenitor level were determined. Patterns of changes were different, but a marked and sustained decrease of both CFU-GM and BFU-E was observed in one case only. The contrast between the apparently rather mild clinical hemotoxicity of dFdC and its in vitro dramatically potent inhibitory activity on hemopoietic progenitors is discussed.

Feasibility and toxicity of combination chemotherapy with ifosfamide, vinorelbine, cisplatin versus ifosfamide, vinorelbine in patients with advanced non small cell lung cancer.

Vinorelbine (VNB) and Ifosfamide (IFO) have recently been proposed for treatment of non small cell lung cancer (NSCLC). The two drugs separately induce response rates in excess of 20% and, when combined, of 32.56%. Cisplatin (DDP) is considered a standard in chemotherapy of NSCLC affected patients. We report data on the feasibility and the toxicity of an IFO, VNB and DDP combination in comparison with IFO, VNB association. Results obtained show that the IFO, VNB, DDP combination has a more severe toxicity profile than the IFO, VNB combination although not to a degree precluding its feasibility. Responses, however, appear somewhat more favorable than in the group treated with the combination IFO, VNB. It is therefore necessary to ascertain if clinical advantages in survival and symptom palliation offered by IFO, VNB, DDP combination outweigh impairment in quality of life due to its significant toxicity.

In vitro synergistic inhibition of human bone marrow hemopoietic progenitor growth by a 3'-azido-3'-deoxy-thymidine, 2',3'-dideoxycytidine combination.

In vitro growth of human normal bone marrow granulocyte-macrophage colony forming units (CFU-GMs) and erythroid burst forming units (BFU-Es) was dose-dependently inhibited by 3'-azido-3'deoxythymidine (AZT) (from 0.1 microM to 4 microM) and 2',3'-dideoxycytidine (ddC) (from 0.01 microM to 1.0 microM). These ranges included minimum in vitro inhibitory concentrations to HIV-1 and concentrations corresponding to plasma level achievable in vivo. A synergistic inhibitory effect, statistically highly significant, was observed when combinations of the two drugs were added to cultures. This severe in vitro toxicity of ddC and the synergistic toxicity of AZT-ddC combinations on hemopoietic progenitor cells should be considered when the two drugs are administered in concurrent or alternating regimens.

Interferon-alpha inhibits CFU-GM mobilization following chemotherapy and G-CSF administration.

Changes in routine hematologic data and in circulating granulocyte-macrophage colony-forming units (CFU-GM) during granulocyte colony-stimulating factor (G-CSF) administration were evaluated in non-small cell lung carcinoma (NSCLC) patients treated with a combination of 5-fluorouracil (5-FU) and cisplatin (DDP) with and without the addition of interferon-alpha (IFN-alpha). The patterns of leukocyte changes following chemotherapy plus G-CSF were similar in both the IFN-alpha-inclusive and the IFN-alpha-devoid courses. However, the twofold increase in CFU-GM observed in patients receiving chemotherapy plus G-CSF was completely absent following the course including IFN-alpha. The activity of G-CSF on the hematologic pattern is seemingly affected by its combination with IFN-alpha treatment. Mechanisms of the possible in vivo interaction among IFNs and hematopoietic growth factors remain to be elucidated.

In vitro activity on myeloid progenitors of a combination of 2-chloro-2'-deoxyadenosine and interferon alpha: the effects of IL-1 and GM-CSF.

The toxic effects of a combination of 2-chloro-2'-deoxyadenosine (CDA) and interferon alpha (IFN-alpha), with and without addition of interleukin 1 (IL-1) and/or granulocyte macrophage colony stimulating factor (GM-CSF), on the in vitro growth of peripheral blood granulocyte macrophage committed progenitors (CFU-GM) from 10 normal subjects were investigated. CDA concentration ranged from 15.6 nmol/l to 1 mumol/l, IFN-alpha sole concentration was 10 IU/ml. IL-1 and/or GM-CSF were added at concentrations of 2000 pg/ml and 10 ng/ml, respectively. CDA induced a dose dependent inhibitory effect on CFU-GM growth. Addition of IFN-alpha increased CFU-GM inhibition induced by CDA only at lower concentrations of the latter. IL-1 and GM-CSF, separately or in combination, did not counteract the inhibitory activity of the CDA-IFN-alpha combination.

Producton of tumor necrosis factor and granulocyte colony stimulating factor by bone marrow accessory cells in myelodysplastic patients.

This paper reports on the production of tumor necrosis factor (TNF) and granulocyte macrophage colony-stimulating factor (GM-CSF) by cultured mononuclear adherent cells derived from bone marrow of 25 patients affected by myelodysplastic syndrome (MDS) of different FAB subtypes. Mean production of GM-CSF was much lower than in controls, without significant differences among different subtypes. Mean production of TNF was similar in MDS patients and in controls, but noteworthy differences were observed between patients with RA, RAEB and RAEB-t and patients with RARS and CMML. Growth of bone marrow granulocyte macrophage and erythroid progenitors did not correlate with TNF and GM-CSF production, although in MDS subtypes with higher GM-CSF levels, colony growth was slightly higher than in subtypes with lower GM-CSF production.

[Alpha interferon in the therapy of polycythemia vera]. / L'interferone alfa nella terapia della policitemia vera.

In previous researches recombinant interferon alpha (IFN-alpha) has been demonstrated to significantly control red cell mass and thrombocytemia in patients with polycythemia vera (PV). Further evaluation of drug effectiveness and of modalities of maintenance therapy is warranted. We treated four patients with PV according to PVSG criteria with IFN-alpha (3 MU subcutaneously three times a week) for five months. Thereafter the starting dose was reduced to 1.5 MU three times a week. Treatment with IFN-alpha at the higher dosage induced regression in sizes of the spleen and a return to normal levels of peripheral blood platelets and leukocytes. Phlebotomies, previously performed to keep under control hematocrit values, were no more needed. During maintenance treatment with IFN-alpha reduced dose platelet level remained in the normal range, spleen size did not show further variation but hematocrit slowly rose and phlebotomies had to be resumed. These results confirm IFN-alpha effectiveness in PV, but suggest the need of relatively high dosages of the drug and difficulties in switching to a maintenance treatment.

[Interferon-alpha in the treatment of myeloproliferative syndromes]. / L'alfa interferone nel trattamento delle sindromi mieloproliferative.

In these last years the use of alpha-interferon (alpha-IFN) has received increasing attention especially in the onco-haematological field. alpha-IFN is particularly useful in the treatment of hairy cell leukemia, cryoglobulinemia, multiple myeloma and myeloproliferative syndromes (SMP). Among these latter conditions alpha-IFN must be considered as the treatment of choice of the early chronic phase of chronic myelogenous leukemia (LMC) in patients not eligible for allogenic bone marrow transplantation because its ability to induce a greater number of clinical remission and cytogenetic responses when compared to the classical chemotherapeutic agents. A myelosuppressive, non-leukemogenic effect and a more selective activity on the neoplastic hemopoiesis appear to be the most important advantages of alpha-IFN therapy. Based on the results obtained in LMC the use of alpha-IFN has been extended to the other SMP, essential thrombocytemia (TE), polycythemia vera (PV), idiopathic myelofibrosis with myeloid metaplasia (MMM). alpha-IFN is able to control thrombocytosis which often characterize the SMP so it appears to be particularly effective in TE. Actually a relatively limited literature is available about the alpha-IFN treatment of PV and MMM and so it is difficult to draw a final conclusion about the effectiveness of the treatment in these disorders. However, especially in PV, the use of this cytokine appears to be promising. The latest reports of the literature are here summarized and discussed.

Cisplatin, 5-fluorouracil and alpha interferon in non small cell lung carcinoma: a toxicity study.

Data are presented on the general and hematological toxicity of a cisplatin (DDP), 5-fluorouracil (5-FU) and alpha interferon (IFN-alpha) association in patients with stage III B or IV non small cell lung cancer (NSCLC). Twenty patients received DDP (100 mg/mq i.v., day 1) and 5-FU (750 mg/mq/day i.v. continuous infusion, days 1 to 4). In ten of these patients IFN-alpha (3 MU s.c., three times weekly, days 1 to 21) was added. General and hematological toxicity was of a similar degree in both groups. Recombinant granulocyte colony stimulating factor (G-CSF; 5 micrograms/kg b.w. s.c. days 7 to 18) induced a sharp increase in peripheral blood GM-CFU level in patients receiving DDP and 5-FU but not in DDP, 5-FU, IFN-alpha treated patients. The results appear to indicate that IFN-alpha modulation of a DDP, 5-FU combination induces an acceptable degree of toxicity.