Minor histocompatibility antigen HA-1 and HA-2 polymorphisms in Taiwan: frequency and application in hematopoietic stem cell transplantation

BACKGROUND

Minor histocompatibility antigens influence the occurrence of graft-vs.-host disease and graft-vs.-leukemia effects after hematopoietic stem cell transplantation (HSCT). We determined the population frequencies of HA-1 and HA-2 alleles in Taiwan and exploited their potential applications in allogeneic HSCT.

METHODS

HA-1 and HA-2 were genotyped using polymerase chain reaction and restriction fragment length polymorphism in healthy controls (221 for HA-1 and 306 for HA-2) and HLA-matched donor-recipient sibling pairs with HSCT (92 for HA-1 and 38 for HA-2). The association of genetic polymorphisms with HSCT outcome was evaluated by univariate and multivariate analyses.

RESULTS

The allele frequencies in controls were 35.3% and 64.7% for HA-1(H) and HA-1(R), and 89.0% and 11.0% for HA-2(V) and HA-2(M), respectively. HA-1 disparity was denoted in 16.3% of HLA-matched donor-recipient sibling pairs, while it was not associated with HSCT outcome. HA-2 disparity was not observed in the donor-recipient pairs studied. The possibilities of using HA-1 and HA-2 variabilities as molecular markers for hematopoietic chimerism after HSCT were 39.2% and 18.4%, respectively.

CONCLUSIONS

Our data provide the information on allele and genotype frequencies of HA-1 and HA-2 in a Taiwanese population, and suggest that prospective genomic typing for HA-1 and HA-2 alleles of the donor and recipient could be a useful approach for molecular identification of hematopoietic chimerism after HSCT, rather than prognosis of clinical outcome.

The challenges of public health education with a particular reference to China

A recent seminar on public health education at the Chinese University of Hong Kong posed some key questions for the future of public health, as well as how the next generation of public health specialists should be educated. This paper summarizes some of the discussions on the future of public health education in China within the context of China's healthcare reforms and trends in global public health education.

Changes in magnetic resonance bone marrow angiogenesis on day 7 after induction chemotherapy can predict outcome of acute myeloid leukemia

Recently, dynamic contrast-enhanced magnetic resonance imaging has been shown to be a non-invasive technique that provides global and functional imaging of bone marrow angiogenesis in acute myeloid leukemia. To assess the clinical implication of changes in angiogenesis shortly after induction chemotherapy, dynamic contrast-enhanced magnetic resonance imaging was performed prospectively before treatment (day 0) and on day 7 in 80 patients with de novo acute myeloid leukemia. We demonstrated that a post-therapeutic reduction in Peak (negative DeltaPeak) compared with the day 0 value was significantly associated with a higher chance of achieving complete remission, and better overall and disease free survival (P=0.022, 0.003 and 0.007, respectively). Cox's multivariate analysis also identified negative DeltaPeak value as an independent good prognostic factor for overall and disease free survival. Our findings provide evidence that the change of Peak on day 7 relative to pre-treatment levels may be a relevant biomarker for early identification of patients who may fail conventional induction chemotherapy (ClinicalTrials.gov Identifier: NCT00172562).

Randomized Phase II Trial of Thalidomide Alone versus Thalidomide Plus Interferon Alpha in Patients with Refractory Multiple Myeloma

The potential synergistic anti-myeloma effect for thalidomide combining with interferon alpha was not yet clear clinically. From March 2001 to January 2004, a total of 28 heavily pretreated multiple myleoma (MM) patients were enrolled in this open-labeled, randomized Phase II study. Patients with refractory MM were randomized to receive either thalidomide alone (200 mg/day up to the maximum dose 800 mg/day, arm B) or the combination of thalidomide and interferon alpha (3 MIU/m(2) subcutaneous injection 3 times weekly, arm A). The objective of this study was to compare the safety and efficacy of thalidomide alone to combined regimen. The patients' characteristics were similar between the 2 arms. However, the average treatment duration was significantly longer in the arm B than the arm A (236 days versus 101 days, p = 0.029). Serum levels of paraprotein decline >/= 25 percent were obtained in 6 of 12 patients (50.0 percent) treated with arm B and 3 of the 16 patients (18.8 percent) treated with arm A. The estimated time to event was 7.9 months (95 percent confidence interval [95%CI], 0.5-15.4) for arm B and 1.5 months (95%CI, 0.0-3.4) for arm A (log-rank test, p = 0.0193). The major adverse events in both arms consisted of neutropenia, anemia, thrombocytopenia, constipation, somnolence, and skin rash. Our study showed that thalidomide alone was effective and tolerated in patients with relapsed or refractory MM. The thalidomide combined with interferon alpha resulted in a lower frequency of paraprotein response, shorter treatment-duration and 25 percent of patients' refusing rate. It may be concluded that the combined regimen is not well tolerated in our patients and needed to be further evaluated in the future.

Haematopoietic stem cell transplantation in Taiwan: past, present, and future

In Taiwan, haematopoietic stem cell transplantation (HSCT) has been used to treat patients with haematological diseases since 1983. Thereafter till 2007, there were 2537 patients who had undergone HSCT in more than 15 hospitals. Their diseases included acute myeloid leukaemia in 27.8% of cases, non-Hodgkin's lymphoma 23.3%, acute lymphoblastic leukaemia 12.8%, chronic myeloid leukaemia 11.9%, severe aplastic anaemia 8.7%, and multiple myeloma 4.1%. Most of the cases received myeloablative conditioning regimens. More than 15% of cases received non-myeloablative regimens, and the mean age of these cases was at least 10 years older than those who received myeloablative regimens. The types of graft included peripheral blood (60.4%) and bone marrow (32.0%). A total of 35% of patients received autologous grafts. Of 1557 allogeneic HSCT patients, 338 (21.7%) received grafts from unrelated donors. Cord blood transplantation has been successfully performed in paediatric patients with thalassaemia major and with a large body size, and adult patients. The incidence of acute graft-versus-host disease was relatively low in Taiwan. On the contrary, a relatively higher proportion of hepatitis B carrier in the recipients had led to a higher incidence of reactivation hepatitis, which was markedly decreased following lamivudine prophylaxis. In conclusion, HSCT has become a routine therapy for major medical centres in Taiwan. Our unique experiences in the past decades also contributed to the progress of HSCT. With the establishment of professional association and patient supportive groups, we hope we can fully improve our daily practice and clinical as well as basic research in HSCT.

Long-term outcome of allogeneic human leukocyte antigen-matched sibling-donor peripheral blood stem cell transplantation in leukaemia patients

Between 1993 and July 2008, a total of 354 leukaemic patients received either allogeneic bone marrow transplantation (BMT) [n = 180] or peripheral blood stem cell transplantation (PBSCT) [n = 174] from human leukocyte antigen-matched sibling donors. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporin A and methotrexate. When comparing with BMT group, patients in the PBSCT group received much higher nucleated cells and CD34+ cells, and had much faster recovery of the neutrophil and platelet counts. The probability of developing acute GVHD was slightly higher in PBSCT patients (P = 0.02). The probability of chronic GVHD (cGVHD) in PBSCT was much higher in PBSCT (70 +/- 5.4%, extensive 48 +/- 6.5%) than in BMT (25 +/- 4.7%, extensive 10 +/- 3.4%; P < 0.001). Chronic GVHD was associated with long-term impairment of life quality and decreased quality-adjusted survival. In standard-risk leukaemia, use of PBSCT was associated with higher cGVHD, transplant-related mortality and a trend for decreased overall survival. The results suggest that allogeneic PBSCT is associated with high incidence of cGVHD in Chinese patients and its long-term risk and benefit remains to be defined in early stage of leukaemia.

Functional polymorphism of CTLA-4 and ICOS genes in allogeneic hematopoietic stem cell transplantation

BACKGROUND

T cells play a critical role in alloimmune recognition and thus contribute to graft-versus-host disease (GVHD) and relapse prevention in hematopoietic stem cell transplantation (HSCT). Cytotoxic T lymphocyte antigen-4 (CTLA-4) and inducible costimulator (ICOS) are costimulatory molecules of T cell activation and their genetic variations can affect the capacity of T cells to become activated or inactivated.

METHODS

We examined CTLA-4 (-318 C/T and +49 A/G) and ICOS (c.602 A/C and c.1624 C/T) genotypes in 123 patients with HSCT and their HLA-matched sibling donors, and then evaluated the impacts of the genetic polymorphisms on GVHD, disease relapse, and survival.

RESULTS

By multivariate analysis, the donor CTLA-4 -318 TT genotype increased the risk of disease relapse (Hazard ratio [HR]: 5.91, 95% confidence interval [CI]: 1.17-29.79, P=0.0313). Recipients who received a graft from a donor with ICOS c.602 CC genotype had worse disease-free survival (HR: 5.97, 95% CI: 1.49-23.87, P=0.0115). Additionally, recipients with ICOS c.1624 TT genotype had worse overall survival (HR: 12.98, 95% CI: 2.58-65.35, P=0.0019). Nevertheless, CTLA-4 and ICOS genotypes were not associated with acute and chronic GVHD.

CONCLUSIONS

Both donor and recipient CTLA-4 and ICOS gene polymorphisms might be of importance for the outcome of allogeneic HSCT.

Estimates of relative risks for cancers in a population after prolonged low-dose-rate radiation exposure: a follow-up assessment from 1983 to 2005

Radiation effects on cancer risks in a cohort of Taiwanese residents who received protracted low-dose-rate gamma-radiation exposures from (60)Co-contaminated reinforcing steel used to build their apartments were studied, and risks were compared to those in other radiation-exposed cohorts. Analyses were based on a more extended follow-up of the cohort population in which 117 cancer cases diagnosed between 1983 and 2005 among 6,242 people with an average excess cumulative exposure estimate of about 48 mGy. Cases were identified from Taiwan's National Cancer Registry. Radiation effects on cancer risk were estimated using proportional hazards models and were summarized in terms of the hazard ratio associated with a 100-mGy increase in dose (HR(100mGy)). A significant radiation risk was observed for leukemia excluding chronic lymphocytic leukemia (HR(100mGy) 1.19, 90% CI 1.01-1.31). Breast cancer exhibited a marginally significant dose response (HR(100mGy) 1.12, 90% CI 0.99-1.21). The results further strengthen the association between protracted low-dose radiation and cancer risks, especially for breast cancers and leukemia, in this unique cohort population.

Detection of BCR-ABL gene mutations in Philadelphia chromosome positive leukemia patients resistant to STI-571 cancer therapy

The ABL-BCR fusion protein is a constitutively activated tyrosine kinase thought to play a central role in chronic myeloid leukemia (CML) and Philadelphia (Ph) chromosome acute lymphoid leukemia (ALL). Targeting the tyrosine kinase activity of ABL-BCR has been shown to be a promising therapeutic strategy in treating this disorder. Among the tyrosine kinase inhibitors, STI571 is a very effective therapeutic agent when administered to CML patients in the stable chronic phase. However, it has been reported that many CML patients with blast cell crisis treated with STI571 relapsed and became resistant to STI571. In order to understand the possible molecular mechanisms underlying STI571 resistance caused by ABL gene mutations, we investigated 19 patients (18 CML patients and 1 Ph (+) ALL patient) who either relapsed after initial response or had no response to STI571 treatment. We used polymerase chain reaction followed by restriction fragment length polymorphism (PCR-RFLP) analysis, dHPLC, and direct DNA sequencing to analyze any possible mutations in exons 5 to 9 of the ABL gene. Our results showed that 5 out of 19 patients had various mutations between exons 5 and 7 of the ABL gene. The Ph (+) ALL patient had a Glu255Lys mutation in exon 5 and a Thr315Ile mutation in exon 7. The Glu255Lys substitution has a G to A change, and the Thr315Ile substitution has a C to T change in the ABL gene. The other unique mutations found in this study include: Tyr253His, Met351Thr, GAA tri-nucleotides insertion, and Leu213Pro.

Receptor tyrosine kinase AXL is induced by chemotherapy drugs and overexpression of AXL confers drug resistance in acute myeloid leukemia

By using a novel profiling analysis of protein tyrosine kinases differentially expressed in the sensitive and refractory leukemia from the same patients we found that AXL was upregulated in drug-resistant leukemia. Furthermore, AXL could be induced by chemotherapy drugs in the acute myeloid leukemia U937 cells and this induction was dependent on the CCWGG methylation status of the AXL promoter. In U937 cells ectopically overexpressing AXL, addition of exogenous Gas6 induced AXL phosphorylation and activation of the Akt and ERK1/2 survival pathways. The Gas6-AXL activation pathway of drug resistance was associated with increased expression of Bcl-2 and Twist. These results show that upregulation of AXL by chemotherapy might induce drug resistance in acute myeloid leukemia in the presence of Gas6 stimulation.

Clinical characteristics and treatment response of Hodgkin's lymphoma in Taiwan

BACKGROUND/PURPOSE

Hodgkin's lymphoma (HL) is particularly rare in Asia, including Taiwan. The report concerning its clinical features and treatment outcomes in Asians is limited. An exploration of the characteristics of HL in this area is of importance for future studies.

METHODS

In this study, 133 patients with HL diagnosed between January 1985 and December 2004 at National Taiwan University Hospital were analyzed retrospectively.

RESULTS

The age distribution revealed a young-adult peak at the age around 20 years. The nodular sclerosis type (NS-HL) was the most common histopathologic subtype (45%), followed by mixed cellularity (29%), lymphocyte predominant (13%), and lymphocyte depleted subtype (2%). The incidence of NS-HL was, however, lower compared with that in the West (around 70%). The male to female ratio was approximately 1:2 in patients with NS-HL, in contrast to the male predominance in patients with other subtypes. Induction therapy led to complete remission (CR) in 87% of patients. At a median follow-up of 78 months, the 10-year overall survival (OS) was 79% in all HL patients and was 90% in those who achieved first CR. In multivariate analysis, the achievement of CR was the only independent factor associated with good OS.

CONCLUSION

The treatment response of HL in Taiwan is good and comparable to that in Western countries. The epidemiologic differences between Taiwan and the West mandate further studies.

RUNX1 gene mutation in primary myelodysplastic syndrome--the mutation can be detected early at diagnosis or acquired during disease progression and is associated with poor outcome

Mutations of Runt-related transcription factor 1 (RUNX1) have been detected in patients with myelodysplastic syndrome (MDS). However, the prognostic implication of RUNX1 mutations in primary MDS is limited. The stage of the disease at which the mutations are acquired and whether they persist during the disease course also remain unclear. We analysed mutations of RUNX1 exons 3-8 in 132 patients with primary MDS and correlated the results with clinical features. Serial studies were performed during the follow-up period. Sixteen patients (12%) had RUNX1 mutations at the time of diagnosis. All RUNX1 mutations that were detected at diagnosis remained unchanged during the clinical course. Two other patients acquired RUNX1 mutations at leukaemic transformation 34 months and 35 months after the diagnosis of MDS. Patients with RUNX1 mutations at diagnosis had higher neutrophil counts and higher frequency of -7/7q deletion than those without. Furthermore, RUNX1 mutation was closely associated with a short overall survival (P = 0.039). This is the first report to demonstrate that RUNX1 mutation can not only be detected early at diagnosis but also acquired during disease progression and is associated with poor prognosis in patients with primary MDS. It may play a role in the development and progression of a subset of primary MDS.

Leukapheresis and cranial irradiation in patients with hyperleukocytic acute myeloid leukemia: no impact on early mortality and intracranial hemorrhage

To assess the role of leukapheresis and cranial irradiation in reducing the incidence of intracranial hemorrhage (ICH) and early death in patients with hyperleukocytic acute myeloid leukemia (AML) and the impact of such treatment on survival. This study retrospectively analyzed the records of 75 patients with hyperleukocytic AML who had a white cell count over 100,000/microL. All patients had de novo AML except for two with therapy-related AML. Various factors were assessed for their impact on morbidity and mortality, particularly the role of pre-induction leukapharesis and cranial irradiation. The most significant risk factors for ICH were the presence of two or more symptoms of leukostasis (odds ratios [OR] 10.6, 95% CI: 2.67-42.02; P = 0.001) and respiratory distress (OR 5.41, 95% CI: 1.44-20.32, P = 0.012). The most significant risk factors for early death were age >or= 65 (OR 4.21, 95% CI: 1.45-12.21, P = 0.008), respiratory failure (OR 3.34, 95% CI: 1.24-9.50, P = 0.018), and two or more symptoms (OR 3.50 95% CI: 1.16-10.52, P = 0.026). Neither leukapheresis nor cranial irradiation were significantly associated with a decreased incidence of ICH (P = 0.349 and 0.378, respectively). Leukapheresis had no significant influence on early death (P = 0.367). The median survival patients receiving no pretreatment was 10.50 months (range 2.58-18.42) and for those receiving pretreatment 1.50 months (range 0.10-3.16; log-rank test, P = 0.062). Leukapheresis and cranial irradiation do not improve survival or decrease the incidence of ICH in adults with hyperleukocytic AML.

WITHDRAWN: Neoadjuvant chemotherapy versus none for resectable gastric cancer

BACKGROUND

Gastric cancer is a major cause of cancer death, and many patients are only diagnosed when the cancer has reached an advanced stage. Neoadjuvant chemotherapy (NAC), that is, chemotherapy administered shortly before surgical treatment, could provide a method of increasing the possibility of complete resection and survival.

OBJECTIVES

To evaluate the effect of neoadjuvant chemotherapy versus none for patients with resectable gastric cancer in terms of efficacy and toxicity.

SEARCH STRATEGY

Electronic databases including Cochrane Library, MEDLINE, EMBASE, CancerLit, Chinese Biomedical Literature Database (CBMDISC) and ongoing clinical trials as well as handsearching of conference proceedings, were searched to retrieve relevant data.

SELECTION CRITERIA

Randomized controlled clinical trials of neoadjuvant chemotherapy on resectable gastric cancer.

DATA COLLECTION AND ANALYSIS

We identified a total of 36 published citations or meeting abstracts. Thirty-two items were excluded. Of the four remaining studies, three stated random allocation but the method of randomization was unclear. Two of these employed allocation concealment by sealed envelope which was controlled by an independent party. None of the trials was double blind. All trials presented a detailed description of the number of withdrawals, dropouts and losses to follow-up.

MAIN RESULTS

Of the four clinical trials enrolled, there were 250 and 332 cases in total, with 106 and 126 deaths at the end of follow-up in the NAC and control group, respectively. The OR (odds ratio) was 1.05 (95%CI: 0.73-1.50), which was not statistically significant. Of the evaluable 129 patients receiving NAC, 28.7% demonstrated either a complete or a partial response. Two studies of NAC in resectable gastric cancer had resection rate data available for analysis The R0 resection rate in the NAC group was comparable to that in the control (OR: 0.96 (95%CI: 0.51-1.83)). The morbidity and mortality of NAC varied with the regimens used preoperatively. Of the 129 patients included in the analyzed studies, some acceptable toxicity was observed.

AUTHORS' CONCLUSIONS

There is no definite evidence of the effectiveness of NAC in resectable gastric cancer, in terms of improvements in patient survival, in the trials we reviewed. Neoadjuvant chemotherapy should not be used routinely in clinical setting until further results from randomized clinical are available. Neoadjuvant chemotherapy of gastric cancer should be applied under the framework of clinical trials.

Expression of angiopoietins and vascular endothelial growth factors and their clinical significance in acute myeloid leukemia

Angiogenic factors play an essential role in normal and pathologic angiogenesis, but their clinical role in acute myeloid leukemia (AML) remains unclear. We investigated the expression of Ang-1, Ang-2, Tie2, VEGF-A, and VEGF-C genes in bone marrow (BM) mononuclear cells by real-time quantitative PCR (RQ-PCR) in a cohort of 126 patients with newly diagnosed de novo AML and normal marrow donors. Here we show that high pre-treatment levels of Ang-2 in the BM indicate an unfavorable prognosis in AML. Only karyotype (hazard ratio 2.19, 95% CI 1.25-3.42, P=0.005) and expression of Ang-2 (hazard ratio 2.05, 95% CI 1.20-3.52, P=0.009), but not other angiogenic factors, were independent prognostic factors for overall survival by multivariate analysis. The prognostic significance of Ang-2 expression was more obvious in the subgroup of patients with intermediate-risk cytogenetics. Subgroup analysis showed that Ang-2 expression had prognostic impact on patients with low (but not high) Ang-1 or Tie2 levels, and on patients with high (but not low) VEGF-A or VEGF-C levels.

Acquisition and Cure of Autoimmune Disease Following Allogeneic Hematopoietic Stem Cell Transplantation

Hematopoietic stem cell transplantation (HSCT) can either cause or eliminate autoimmune disease. Here, we report two cases. One was a 33-year-old woman with myelodysplastic syndrome (refractory anemia) who received bone marrow transplantation from her human leukocyte antigen (HLA)-identical sister who had a history of Graves disease. Antithyroid antibodies, including antimicrosomal antibody and antithyroglobulin antibody, appeared 4 months after transplantation. Clinical hyperthyroidism appeared 7 months after transplantation, and a hypothyroid state was noted 2 months later. The other case was a 50-year-old woman with Sjgrens syndrome and hypothyroidism who was diagnosed with peripheral T cell non-Hodgkins lymphoma. She received allogeneic peripheral blood stem cell transplantation (PBSCT) from her histocompatible sister owing to only partial response to traditional chemotherapy. Cure of lymphoma and remission of Sjgrens syndrome was noted 4 years after PBSCT. These two illustrative cases, one of acquisition of hyperthyroidism and the other of remission of Sjgrens syndrome after transplantation, highlights that HSCT can induce adoptive autoimmune disease or cure coincidental autoimmune disease. Donor selection and attentive monitoring is required in such circumstances.

Mycobacterium tuberculosis Bacteremia in HIV-negative Patients

BACKGROUND/PURPOSE

Limited information exists about the epidemiologic characteristics of HIV-negative patients with Mycobacterium tuberculosis bacteremia (MTB).

METHODS

We retrospectively surveyed tuberculosis (TB) cases reported at National Taiwan University Hospital between 1997 and 2003. Demographic data, underlying diseases or conditions, clinical, microbiologic and radiologic findings and therapy were collected. Long-term outcome was evaluated at 1 year after initiation of anti-TB agents.

RESULTS

During the study period the incidence of MTB bacteremia in HIV-negative patients and HIV-positive patients were 0.024 and 6.2 per 1000 discharges, respectively (p<0.01). All 11 HIV-negative patients were males and eight (73%) were more than 50 years old. The most common underlying diseases/conditions were immunosuppressive therapy (64%) and heart disease (55%). Fever (80%), lymphopenia (75%) and pulmonary symptoms (58%) were the most common presentations. Ten patients were septic, two had septic shock and two had acute respiratory distress syndrome on admission. The median interval between admission and initiation of therapy for those who were cured was 6 days. Six (55%) died of TB and/or their underlying diseases. Of the six patients who died, the median survival after collection of positive blood culture was 19 days for three treated patients and 7 days for three untreated patients (p=0.01).

CONCLUSION

This case series demonstrates the wide spectrum of the initial presentation of HIV-negative patients with MTB bacteremia. The case fatality rate was high and was likely due to immunocompromised status and no anti-TB treatment prior to death. A high index of suspicion for TB and blood culture for MTB provides an additional simple and noninvasive diagnostic method to detect disseminated TB in endemic areas.

Neoadjuvant chemotherapy versus none for resectable gastric cancer

BACKGROUND

Gastric cancer is a major cause of cancer death, and many patients are only diagnosed when the cancer has reached an advanced stage. Neoadjuvant chemotherapy (NAC), that is, chemotherapy administered shortly before surgical treatment, could provide a method of increasing the possibility of complete resection and survival.

OBJECTIVES

To evaluate the effect of neoadjuvant chemotherapy versus none for patients with resectable gastric cancer in terms of efficacy and toxicity.

SEARCH STRATEGY

Electronic databases including Cochrane Library, MEDLINE, EMBASE, CancerLit, Chinese Biomedical Literature Database (CBMDISC) and ongoing clinical trials as well as handsearching of conference proceedings, were searched to retrieve relevant data.

SELECTION CRITERIA

Randomized controlled clinical trials of neoadjuvant chemotherapy on resectable gastric cancer.

DATA COLLECTION AND ANALYSIS

We identified a total of 36 published citations or meeting abstracts. Thirty-two items were excluded. Of the four remaining studies, three stated random allocation but the method of randomization was unclear. Two of these employed allocation concealment by sealed envelope which was controlled by an independent party. None of the trials was double blind. All trials presented a detailed description of the number of withdrawals, dropouts and losses to follow-up.

MAIN RESULTS

Of the four clinical trials enrolled, there were 250 and 332 cases in total, with 106 and 126 deaths at the end of follow-up in the NAC and control group, respectively. The OR (odds ratio) was 1.05 (95%CI: 0.73-1.50), which was not statistically significant. Of the evaluable 129 patients receiving NAC, 28.7% demonstrated either a complete or a partial response. Two studies of NAC in resectable gastric cancer had resection rate data available for analysis The R0 resection rate in the NAC group was comparable to that in the control (OR: 0.96 (95%CI: 0.51-1.83)). The morbidity and mortality of NAC varied with the regimens used preoperatively. Of the 129 patients included in the analyzed studies, some acceptable toxicity was observed.

AUTHORS' CONCLUSIONS

There is no definite evidence of the effectiveness of NAC in resectable gastric cancer, in terms of improvements in patient survival, in the trials we reviewed. Neoadjuvant chemotherapy should not be used routinely in clinical setting until further results from randomized clinical are available. Neoadjuvant chemotherapy of gastric cancer should be applied under the framework of clinical trials.

Epidemiological characteristics of diabetes mellitus and impaired glucose regulation in a Chinese adult population: the Shanghai Diabetes Studies, a cross-sectional 3-year follow-up study in Shanghai urban communities

AIMS/HYPOTHESIS

To estimate the prevalence and incidence of diabetes mellitus and impaired glucose regulation (IGR) in a Chinese population aged 20-94 years.

SUBJECTS AND METHODS

A group of 5,628 randomly selected adults, aged 20-94 years, living in the Huayang and Caoyang communities in Shanghai, China, were investigated between 1998 and 2001. During 2002-04, 2,666 subjects were followed up. All the participants underwent anthropometric measurements, blood biochemical analyses and a 75-g OGTT.

RESULTS

Based on the 2000 census data of China, the age-standardised prevalences were 6.87% for diabetes and 8.53% for IGR at baseline. More than two in five cases with diabetes were undiagnosed. The age-adjusted prevalence of diabetes and IGR increased with age. The age-adjusted prevalences of hypertension, dyslipidaemia and overweight in males were significantly higher (p < 0.001) than in females. The 3-year cumulative incidence rates of diabetes and IGR were 4.96 and 11.10%, respectively. The relative risk of developing diabetes was significantly higher in subjects with IGR than in subjects with NGT (p < 0.001).

CONCLUSIONS/INTERPRETATION

The prevalence and incidence rates for diabetes or IGR have increased dramatically over the last decades, especially in younger age groups. A large proportion of cases are undiagnosed. We strongly recommend that population-based diabetes screening programmes should be implemented and generalised for younger people.

Epidemiology of multiple myeloma in Taiwan

BACKGROUND

The incidence of multiple myeloma (MM) is lower in Asia than in western countries. However, no data are available on descriptive epidemiology of MM in Chinese.

METHODS

From 1979 to 2003, 3602 MM patients were registered in the Taiwan National Cancer Registry. The annual incidence and mortality were calculated and age-standardized to the world standard population in the year 2000. Age-period-cohort effects on incidence were analyzed. The salient clinical data of 526 MM patients in a single institute were also investigated.

RESULTS

From 1979 to 2003, the average age-adjusted incidence per 100,000 population was 0.75. The incidence increased with age to a peak of 5.2 in those aged 75-79 years. In addition to age, remarkable period and birth cohort effects were found to contribute to increased incidence of MM. The age-adjusted mortality also increased, which accounted for an average of 0.59 per 100,000 deaths; however, the fatality rate was steady at 80%. Clinical and laboratory characteristics and treatment outcomes of the 526 MM patients were similar to those reported elsewhere. Remarkably, extramedullary myeloma (extra-MM) at diagnosis was more common in patients younger than 55 years of age than in others (43% vs 13%, P < .001).

CONCLUSIONS

Incidence of MM in Taiwan has dramatically increased in recent years and is associated with a birth-cohort effect. There are no apparent differences in treatment outcome between MM patients in Taiwan and in other countries. However, prevalence of extra-MM is higher in patients younger than 55 years of age.

Quantification of trimetazidine in human plasma by liquid chromatography-electrospray ionization mass spectrometry and its application to a bioequivalence study

A rapid, sensitive and specific liquid chromatography-electrospray ionization mass spectrometric (LC-ESI-MS) method has been developed for the quantification of trimetazidine in human plasma. The analyte and the internal standard (pseudoephedrine) were extracted from plasma samples with n-hexane-dichloromethane (1:1, v/v) and analyzed on a C18 column. The chromatographic separation was achieved within 3.5 min using the mobile phase consisting of methanol/0.05% formic acid (80:20, v/v) and the flow rate was 1.0 ml/min. Ion signals m/z 181.0 and 148.0 were measured in the positive mode for trimetazidine and pseudoephedrine, respectively. The calibration curves were linear within the range of 0.4 to approximately 120 ng/ml. The lower limit of quantification (LLOQ) was 0.4 ng/ml with 0.5 ml plasma sample. The intra- and inter-day precisions were lower than 12% in terms of relative standard deviation (RSD). The inter-day relative error (RE) as determined from quality control samples (QCs), ranged from -1.4% to 3.3%. This validated method was successfully applied to the bioequivalent evaluation of two brands of trimetazidine tablets in 20 healthy volunteers.

Clinical implications of SOCS1 methylation in myelodysplastic syndrome

The suppressor of cytokine signalling-1 (SOCS1) protein is a tumour suppressor. Hypermethylation of SOCS1 gene, resulting in transcriptional silencing, is suggested to play an important role in cancer development. We sought to characterise SOCS1 methylation in primary myelodysplastic syndrome (MDS) and clarify its clinical implications. The methylation status of SOCS1 was analysed by methylation-specific polymerase chain reaction in 114 patients with primary MDS and serial studies were performed in 29 of them. SOCS1 methylation occurred in 54 patients (47.4%), and was more frequent in patients with high-risk MDS than in those with low-risk (52.6% vs. 25.8%, P = 0.011). SOCS1 methylation was closely associated with NRAS mutation (P = 0.010) and inversely associated with good-risk karyotype (P = 0.021). With a median follow-up of 17 months (range: 1-231 months), two patients acquired SOCS1 methylation during disease progression. In two patients, SOCS1 methylation present at diagnosis, disappeared after haematopoietic stem cell transplantation. Patients with SOCS1 methylation had a higher cumulative risk of leukaemic transformation than those without (55.8% vs. 27.7% at 3 years, P = 0.004). This difference remained significant within the subgroup of patients with high-risk MDS (67.3% vs. 45.1% at 3 years, P = 0.045). This is the first report to demonstrate the clinical relevance of SOCS1 methylation in MDS. It may play an important role in the pathogenesis of MDS, especially among patients with high-risk subtypes.

Acupuncture for stroke rehabilitation

BACKGROUND

Stroke is the third leading cause of death in Western society; in China it is the second most common cause of death in cities and the third in rural areas. It is also a main cause of adult disability and dependency. Acupuncture for stroke has been used in China for hundreds of years and is increasingly practiced in some Western countries.

OBJECTIVES

To assess the efficacy and safety of acupuncture for patients with stroke in the subacute or chronic stage.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (November 2005), the Cochrane Complementary Medicine Field Trials Register (November 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005), MEDLINE (1966 to November 2005), EMBASE (1980 to November 2005), CINAHL (1982 to November 2005), AMED (1985 to November 2005), the Chinese Stroke Trials Register (November 2005), the Chinese Acupuncture Trials Register (November 2005), the Chinese Biological Medicine Database (1977 to November 2005), the National Center for Complementary and Alternative Medicine Register (November 2005), and the National Institute of Health Clinical Trials Database (November 2005). We handsearched four Chinese journals and checked reference lists of all papers identified for further trials.

SELECTION CRITERIA

Truly randomised unconfounded clinical trials among patients with ischemic or hemorrhagic stroke, in the subacute or chronic stage, which compared acupuncture involving needling with either placebo acupuncture, sham acupuncture or no acupuncture.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed quality, extracted and cross-checked the data.

MAIN RESULTS

Five trials (368 patients) met the inclusion criteria. Methodological quality was considered inadequate in all trials. Although the overall estimate from four trials suggested the odds of improvement in global neurological deficit was higher in the acupuncture group compared with the control group (odds ratio (OR) 6.55, 95% confidence interval (CI) 1.89 to 22.76), this estimate may not be reliable since there was substantial heterogeneity (I(2 )= 68%). One trial showed no significant improvement of motor function between the real acupuncture group and the sham acupuncture group (OR 9.00, 95% CI 0.40 to 203.30), but the confidence interval was wide and included clinically significant effects in both directions. No data on death, dependency, institutional care, change of neurological deficit score, quality of life or adverse events were available.

AUTHORS' CONCLUSIONS

Currently there is no clear evidence on the effects of acupuncture on subacute or chronic stroke. Large, methodologically-sound trials are required.

Pathological fracture as a manifestation of extramedullary blastic crisis in chronic myelogenous leukemia: report of one case

A three-year-old girl with chronic myelogenous leukemia (CML) experienced a pathological fracture of her femur after a demonstrated osteolytic bone lesion. Extramedullary disease (EMD) was diagnosed following the histologic findings of a biopsy of the osteolytic lesion. Frank blast crisis in the bone marrow followed one month later. This was the youngest patient to have been reported in English literature of Philadelphia chromosome positive (Ph+) CML with isolated bony EMD and pathological fracture. Treatment with a tyrosine kinase inhibitor, imatinib mesylate (Gleevec), in bone marrow accelerated phase of CML was failed to reverse the progression of blastic transformation, neither in the extramedullary bone lesion nor in the bone marrow.

Nucleophosmin Mutations in De novo Acute Myeloid Leukemia: The Age-Dependent Incidences and the Stability during Disease Evolution

Nucleophosmin (NPM) mutations have been found in a significant proportion of adults with de novo acute myeloid leukemia (AML), especially in those of a normal karyotype. These results provide a basis for studies of the pathogenesis in this specific subgroup of AML. In this study, NPM mutations were analyzed in 173 Chinese patients of de novo AML, including adults and children. We found that NPM mutations were present in 19.1% of the overall population and 40.3% of those with a normal karyotype. Adults had a significantly higher incidence of NPM mutations than children [32 of 126 (25.4%) versus 1 of 47 (2.1%), P < 0.001]. NPM mutations were closely associated with normal karyotype (P < 0.001) and internal tandem duplication of FLT3 (P = 0.002), but negatively associated with CEBPA mutations (P = 0.032) and expression of CD34 (P < 0.001) and HLA-DR (P = 0.003). Serial analyses of NPM mutations showed the mutation disappeared at complete remission, but the same mutation reappeared at relapse, except for one who lost the mutation at the second relapse, when new cytogenetic abnormalities emerged. None acquired novel mutations during the follow-up period. In conclusion, NPM mutations occur in an age-dependent fashion. Moreover, the findings that NPM mutations are stable during disease evolution and closely associated with disease status make it a potential marker for monitoring minimal residual disease.

The usefulness of the PlateliaCandidaantigen in a patient with acute lymphocytic leukemia and chronic disseminated candidiasis

We report a protracted course of disseminated candidiasis due to Candida tropicalis in a 17-year-old man with acute lymphocytic leukemia. Despite adequate antifungal therapy (amphotericin B), C. tropicalis was recovered from biopsy specimens 25 days (skin) and 109 days (kidney) after the first positive blood cultures. While blood cultures became negative for C. tropicalis 11 days after the initiation of treatment, mannanemia persisted and became negative only after 130 days of antifungal therapy. Thus, antigen assays provided indicators of antifungal response. Differential diagnosis was difficult for this patient with the observation of persistent lesions in image studies. With positive results of antigen assays, an invasive procedure might be avoided and preemptive antifungal treatment could be initiated in a timely manner. Anti-mannan antibody remained undetectable up to 164 days after first positive blood culture despite the patient's recovery from neutropenia and recruitment of neutrophils in the tissue (skin).

Acupuncture for nocturnal enuresis in children: a systematic review and exploration of rationale

OBJECTIVES

This review identified reports of acupuncture for childhood nocturnal enuresis, with the aim of ascertaining whether acupuncture is efficacious and or better than standard therapy for treating enuresis.

MATERIALS AND METHODS

Studies of children of either gender <18 years of age who received acupuncture treatment for nocturnal enuresis, were considered. The primary outcome measure was change in the mean number of wet episodes following treatment. Electronic searching was supplemented by hand searching of western medicine and traditional Chinese medicine (TCM) journals along with English language alternative medicine journals. Trials were assessed for quality and sources of bias. Meta-analysis was performed and the overall weighted odds ratio (OR) and associated 95% confidence interval (CI) were computed using the fixed effect model; the Forest plot was used to demonstrate results.

RESULTS

Two hundred six abstracts were identified, of which 11 studies were eligible for data extraction. All the trials were of low methodological quality. There was some evidence that acupuncture is useful for nocturnal enuresis when used in conjunction with other treatment that may also include a different form of acupuncture (OR 3.98, CI: 2.2-7.2). When one form of acupuncture is compared with another there was marked heterogeneity, implying that some forms of acupuncture are effective.

CONCLUSION

This review provides tentative evidence for the efficacy of acupuncture for the treatment of childhood nocturnal enuresis. Due to the low methodological quality of studies, evidence to identify, which parameters of acupuncture work best, is lacking. More rigorous trials are clearly warranted.

Diffuse pulmonary infiltrates after bone marrow transplantation: the role of open lung biopsy

BACKGROUND

Diffuse pulmonary infiltrates is the major complication and cause of mortality after bone marrow transplantation. We analyzed the etiologies and prognostic factors in bone marrow recipients with diffuse pulmonary infiltrates and assessed the role of open lung biopsy in managing this complication.

METHODS

Medical records of patients with diffuse pulmonary infiltrates after bone marrow transplantation were reviewed. Possible prognostic factors were analyzed by multivariate logistic regression.

RESULTS

Sixty-eight (20%) of 341 bone marrow recipients had diffuse pulmonary infiltrates and 34 died. Thirty-five underwent open lung biopsy, resulting in therapeutic changes in 22 (63%) and clinical improvement in 16 (46%). The leading diagnoses were idiopathic interstitial pneumonitis (40%) and cytomegalovirus pneumonitis (20%). Cytomegalovirus pneumonitis caused radiographically observable interstitial infiltrates exclusively and was frequently associated with hepatitis. Idiopathic interstitial pneumonitis resulted in either diffuse ground-glass opacity or interstitial infiltrates. Three (9%) patients had miliary tuberculosis. Respiratory failure (p < 0.001) and acute graft-versus-host disease (p = 0.016) were the poor prognostic factors.

CONCLUSIONS

Among bone marrow recipients, we found diffuse pulmonary infiltrates in 20% and a mortality rate of 50%. Idiopathic interstitial pneumonitis and cytomegalovirus pneumonitis were the most common causes and should be suspected in patients with diffuse interstitial infiltrates. In endemic areas, miliary tuberculosis should be suspected in bone marrow recipients with diffuse reticulonodular lesions. Respiratory failure and acute graft-versus-host disease were poor prognostic factors. By establishing a correct diagnosis, open lung biopsy led to treatment changes in about two-thirds of these patients.

Characterization of CEBPA Mutations in Acute Myeloid Leukemia: Most Patients with CEBPA Mutations Have Biallelic Mutations and Show a Distinct Immunophenotype of the Leukemic Cells

PURPOSE

The transcription factor CCAAT/enhancer binding protein alpha, encoded by the CEBPA, is crucial for the differentiation of immature granulocytes. Mutation of the CEBPA may play an important role in leukemogenesis and prognosis. We sought to characterize the CEBPA mutation in acute myeloid leukemia (AML) and to clarify if there is a distinct immunophenotype for leukemic cells with the mutation.

EXPERIMENT DESIGN

One hundred and four patients with de novo AML were evaluated for the CEBPA mutation and immunophenotype of the leukemic cells.

RESULTS

Twenty-two distinct mutations were identified in 16 (15%) of 104 AML patients. Fourteen patients had biallelic mutations, mostly involving both the NH(2)-terminal TAD1 region and the COOH-terminal basic leucine zipper domain (bZIP). The mutations in the bZIP region were always tandem duplications and were located at hot-spot regions for topoisomerase II sites. Sequential study of the CEBPA mutations showed that the mutations disappeared at complete remission but the same mutations reappeared at relapse. None of the patients developed novel mutations during the follow-up period. Patients with CEBPA mutations had significantly higher incidences of CD7 (73%), CD15 (100%), CD34 (93%), and HLA-DR (93%) expression on the leukemic cells.

CONCLUSION

These data revealed that most AML with CEBPA mutations were associated with an immunophenotype of HLA-DR(+)CD7(+)CD13(+)CD14(-)CD15(+)CD33(+)CD34(+). The close relationship of CEBPA mutations with the leukemia status of the patients and the concordance of mutation in presenting and relapse samples implicate the CEBPA mutation as a potential marker for monitoring minimal residue disease.

Intrapartum Cesarean Delivery After Successful External Cephalic Version

OBJECTIVE

We sought to estimate whether the risk of intrapartum cesarean delivery is higher in pregnancies after successful external cephalic version.

DATA SOURCES

We searched the MEDLINE, PubMed, EMBASE, and Cochrane Library databases to identify relevant studies. Abstracts of the American College of Obstetricians and Gynecologists Annual Clinical Meeting and the Society for Maternal-Fetal Medicine Annual Meeting were searched by hand.

STUDY SELECTION

Studies published between 1980 and 2002 that provided data allowing us to estimate the cesarean rate in both pregnancies after successful version and spontaneous cephalic-presenting pregnancies were selected.

TABULATION, INTEGRATION, AND RESULTS

Relative risks (RRs) and 95% confidence intervals (CIs) between the 2 compared groups were calculated. We used a meta-analysis to assess the heterogeneity of the studies and to combine the results from the included studies. Six eligible studies were identified. The cesarean rate was 27.6% in pregnancies after successful version and 12.5% in cephalic-presenting pregnancies. The combined RR and 95% CI was 2.04 (1.43-2.91). The increased cesarean rate in pregnancies after successful version was accounted for primarily by a higher incidence of emergency cesarean delivery for dystocia and fetal distress; the RR (95% CI) for these 2 events was 2.19 (1.38-3.48) and 2.10 (1.18-3.75), respectively.

CONCLUSION

The intrapartum cesarean delivery rate after successful version is 2 times that in pregnancies where there is spontaneous cephalic presentation. Pregnancies after successful version should not be considered the same as a normal pregnancy.

Trends and antimicrobial resistance of pathogens causing bloodstream infections among febrile neutropenic adults with hematological malignancy

BACKGROUND AND PURPOSE

The microbiological spectrum in cancer patients with febrile neutropenia has changed over the past several decades in western countries. The growing incidence of antimicrobial resistance is an inevitable consequence of the widespread use of antibiotics in medical settings. The aim of this study was to clarify the trends and antimicrobial resistance among pathogens causing bloodstream infections in febrile neutropenic adults with hematological malignancies.

METHODS

The characteristics of pathogens causing bloodstream infection isolated from patients with febrile neutropenia who were treated at National Taiwan University Hospital from 1996 to 2001 were reviewed. A total of 1174 pathogens were isolated from 3093 admissions to a hematological ward during this period. Among them, 738 isolates were recovered from patients with febrile neutropenia.

RESULTS

The majority (93%) of these neutropenic febrile patients had underlying acute leukemia or lymphoma. Gram-negative bacteria accounted for 57% of isolated pathogens, followed by Gram-positive bacteria (32%), fungi (7%), and anaerobes (3%). In decreasing frequency, Escherichia coli (13%), Klebsiella pneumoniae (12%), Enterobacter cloacae (7%), Pseudomonas aeruginosa (6%), and Acinetobacter baumannii (5%) were the predominant Gram-negative bacteria, while coagulase-negative staphylococci (13%), viridans group streptococci (4%), and Staphylococcus aureus (4%) were the major Gram-positive pathogens. Two-thirds (20/30) of S. aureus isolates were resistant to oxacillin. No vancomycin-resistant enterococci were isolated. Resistance to cefotaxime was found in 63% of E. cloacae, 13% of K. pneumoniae and 10% of E. coli. Overall, 33% of E. coli and 13% of K. pneumoniae were resistant to ciprofloxacin.

CONCLUSIONS

This study indicates that the microbiological spectrum of microorganisms causing bloodstream infections in neutropenic febrile patients with hematological malignancies at National Taiwan University Hospital is different from western countries in that Gram-negative bacteria remain the predominant pathogens. Antimicrobial resistance among these pathogens is high and E. coli and K. pneumoniae isolates with resistance to third-generation cephalosporins and ciprofloxacin are increasing.

Treatment outcome and pattern of failure in 77 patients with sinonasal natural killer/T-cell or T-cell lymphoma

BACKGROUND

Sinonasal natural killer (NK)/T-cell or T-cell lymphoma behaves quite differently from other lymphomas. The objective of this study was to investigate clinical features, treatment outcomes, and failure patterns in patients with this type of sinonasal lymphoma.

METHODS

From September, 1977 to December, 2000, 77 patients with sinonasal NK/T-cell lymphoma or T-cell lymphoma who had received radiotherapy (R/T), chemotherapy (C/T), or both (R/T and C/T) were evaluated retrospectively.

RESULTS

Fifty-six patients (73%) had locoregional disease only, and 21 patients (27%) had systemic involvement. Forty-four patients (57%) achieved a complete remission (CR). The 5-year overall survival rate was 36% (median follow-up, 89 months). Achievement of CR was the only prognostic factor for survival in multivariate analysis. Among patients with locoregional disease, the CR rate was 63%, and the 5-year overall survival rate was 42%. Combined R/T and C/T or R/T alone resulted in better survival compared with C/T alone (5-year survival rates, 59%, 50%, and 15%, respectively; P = 0.01). Incidences of locoregional and systemic failure were 43% and 30%, respectively. Outcome was dismal for patients with systemic disease, with a CR rate of 43% and a 5-year survival rate of 25%. Only 2 of 21 patients had sustained remissions. The locoregional and systemic failure rates were 57% and 71%, respectively.

CONCLUSIONS

Treatment outcomes were unsatisfactory for patients with locoregional and systemic sinonasal NK/T-cell or T-cell lymphoma. R/T could not control locoregional disease satisfactorily, and C/T was unable to eradicate systemic disease in many patients. High-dose therapy may be worth studying in these patients. New treatments should be investigated to increase remission rates, prevent failure, and improve survival.

Clinical and Microbiological Characteristics ofRhizobium radiobacterInfections

Data obtained from 1996 to 2002 on 13 patients with Rhizobium radiobacter infections were analyzed. Ten patients (76%) had underlying hematological malignancy or solid-organ cancer. Six patients (46%) had febrile neutropenia during the course of R. radiobacter infection. The majority (54%) of infections were catheter-related bacteremia, and 92% of infections were hospital acquired. All the patients survived. Eighteen isolates were recovered from the 13 patients, and each isolate was susceptible to cefepime, piperacillin-tazobactam, carbapenems, and ciprofloxacin. The pulsed-field gel electrophoresis profiles differed among the isolates recovered from different patients, indicating the absence of nosocomial spread of the organism.

Interventions for preventing infection in nephrotic syndrome

BACKGROUND

Infection is one of the most common complications and still remains a significant cause of morbidity and occasionally mortality in patients, especially children with nephrotic syndrome. Many different prophylactic interventions have been used or recommended for reducing the risks of infection in nephrotic syndrome in clinical practice. Whether the existing evidence is scientifically rigorous and which prophylactic intervention can be recommended for routine use based on the current evidence is still unknown.

OBJECTIVES

To assess the benefits and harms of any prophylactic interventions for reducing the risk of infection in children and adults with nephrotic syndrome.

SEARCH STRATEGY

We searched the Cochrane Renal Group Specialised Register (January 2003), The Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library Issue 1, 2003), MEDLINE and Pre-MEDLINE (1966 - February 2003), EMBASE (1980 - February 2003), China Biological Medicine Database (CBMdisc, 1979 - December 2002), reference lists of nephrology textbooks, review articles, relevant trials and abstracts from nephrology scientific meetings without language restriction.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs comparing any prophylactic interventions (pharmacological or non-pharmacological) for preventing any infection in children and adults with nephrotic syndrome.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed and extracted information. Information was collected on method, participants, interventions and outcomes ( appearance of infection, mortality, quality of life and adverse events).

MAIN RESULTS

Five RCTs conducted in China, including 308 children with nephrotic syndrome were identified. No trials were identified in adults. All trials compared one kind of prophylactic pharmacotherapy (IVIG, thymosin or a compound of Chinese medicinal herbs - TIAOJINING) in addition to baseline treatment with baseline treatment alone. No RCTs were identified comparing antibiotic or non-pharmacological prophylaxis, or pneumococcal vaccination. Three trials showed a significantly better effect of IVIG on preventing nosocomial or unspecified infection in children with nephrotic syndrome (RR 0.39, 95% CI 0.18 to 0.82). Thymosin and TIAOJINING were also effective for reducing the risks of infection in children with nephrotic syndrome with RR 0.50 (95%CI 0.26 to 0.97) and 0.59 (95%CI 0.43 to 0.81) respectively. No serious adverse events were reported.

REVIEWERS' CONCLUSIONS

IVIG, thymosin and TIAOJINING may have positive effects on prevention of nosocomial or unspecified infection with no obvious serious adverse events in children with nephrotic syndrome. However the methodological quality of all trials was poor, the sample sizes small and all studies were from China, and thus there is no strong evidence on the effectiveness of these interventions.

Reduction of leukocyte count is associated with thalidomide response in treatment of multiple myeloma

Fifty Taiwanese patients with relapsed and/or refractory multiple myeloma (MM) were treated with thalidomide on a dose-escalation schedule, commencing with 100 mg/d nightly and incremented either to the maximally tolerated dose or 800 mg/d. Twenty-two patients (44%) responded, with 10 (45.5%) classified as partial remission and 12 (54.5%) minimal response (MR). Complete response did not occur. Of the 28 non-responders, 14 were progressive disease and 14 stable. The median time from commencement of thalidomide treatment to initial achievement of MR was 29 days (range, 8~155), and the corresponding thalidomide dose was 200 mg/d (range, 100~500). The median tolerated dose of thalidomide for the entire sample was 400 mg/d (range, 100~800), with only two (4%) able to tolerate 800 mg/d. Comparing responsive and non-responsive patients, statistically significant differences were not demonstrated for any characteristics except for CRP level and percentage cytogenetic change, which was slightly higher in the latter group relative to the former. Of particular interest, 18 of the 22 responders experienced transient reduction of leukocyte count preceding the attainment of significant reduction in M-proteins in comparison to only four of the 28 non-responders (82% vs. 14%; p<0.001). The median time from commencement of thalidomide treatment to attainment of minimal leukocyte count was 28 days (range, 7~150), with a mean of 2.19x10(9)/l (range, 0.96~3.35x10(9)/l). Leukopenia was generally transient, with rapid recovery despite subsequent continuation of thalidomide. Levels of other non-hematologically adverse effects attributed solely to thalidomide were generally acceptable. For 25 patients, thalidomide treatment was supplemented with low-dose dexamethasone (4 mg, every other day). Of these, 11 had relapsed from and 14 were primarily refractory to thalidomide treatment. Nine of the 25 dexamethasone-supplemented patients were responders (36%). Of particular note were the unusual events noted with this thalidomide-dexamethasone combination, including vascular thrombosis, acute cholecystitis, idiopathic interstitial lung disease and sudden cardiac death. Our results suggest that thalidomide is also effective for Taiwanese patients with refractory and/or relapsed MM. Importantly, the transient reduction in leukocyte count after commencement of thalidomide treatment may serve as a clinical predictor for response. Adverse effects should be carefully monitored when combining thalidomide and dexamethasone, however.

Survival-weighted health profile for long-term survivors of acute myelogenous leukemia

The objective of this study was to use survival-weighted psychometric scores (SWPS) to construct a 'health profile' for long-term survivors of acute myelogenous leukemia (AML). The study cohort included all patients who had been diagnosed and treated in our institution from 1985 to 1999 and achieved complete remission after standard chemotherapy (n = 259). One hundred and four patients were interviewed by the European Organization for the Research and Treatment of Cancer (EORTC)-QLQ-C30 questionnaire and the brief form of World Health Organization quality of life questionnaire (WHOQOL-BREF) to estimate the quality of life (QOL) function of the cohort. Forty-one patients underwent bone marrow transplantation (BMT) as consolidation or salvage therapy; 63 received chemotherapy alone. SWPS for every functioning domain and symptom item was obtained by direct integration of the mean QOL function with the survival function of the cohort. A Monte Carlo method was used to extrapolate the life-long SWPS beyond the follow-up limit. The mean scores of EORTC-QLQ-C30 and WHOQOL-BREF did not differ significantly between patients who received BMT or those who received chemotherapy only (p > 0.01). In mean SWPS, patients who received BMT had significantly (p < 0.01) better SWPS in all of the functioning domains and symptom items of EORTC-QLQ-C30 and all four domains of WHOQOL-BREF. However, when the life-long extrapolation of SWPS was made, these differences diminished in global health and several symptom items of EORTC-QLQ-C30 as well as in the social and environmental domains of WHOQOL-BREF. Patients' perspective on QOL may be domain-specific and may evolve over time. SWPS may be useful to evaluate the efficacy of different treatment strategies for AML. Confirmation of the relative merit of BMT vs. chemotherapy alone from prospective studies is needed.

SOCS1 methylation in patients with newly diagnosed acute myeloid leukemia

The proliferation and differentiation of hematopoietic precursor cells depend on various cytokines. The suppressor of cytokine signaling-1 (SOCS1) down-regulates Janus kinases/signal transducers and activators of transcription (JAK/STAT) pathway activity and inhibits the biological effects of cytokines. SOCS1 has been shown to have tumor-suppressor activity, and methylation of this gene, resulting in transcriptional silencing, has been found in 65% of hepatocellular carcinoma and has been suggested to play an important role in the development of the cancer. The methylation status of the SOCS1 gene in acute myeloid leukemia (AML) has not been reported before. In this study, we analyzed SOCS1 methylation in 89 patients with newly diagnosed AML and correlated the result with immunophenotypes, cytogenetics, clinical features, and treatment outcome. SOCS1 methylation was found in the leukemic cells from 53 patients (60%). Thirteen (76%) of the 17 patients with t(15;17) had SOCS1 methylation, whereas this gene was methylated in only one (11%) of the nine patients with t(8;21). The frequencies of SOCS1 methylation among various cytogenetic subgroups differed significantly (P = 0.014). Other clinical and laboratory parameters and the disease-free survival and overall survival were similar between patients with and without SOCS1 methylation. In conclusion, SOCS1 methylation occurs in more than half of AML cases, correlates with cytogenetic abnormalities, and may play an important role in the development of subsets of AML.

Combination of 13-cis retinoic acid and interferon-alpha in the treatment of recurrent or refractory peripheral T-cell lymphoma

We previously reported the therapeutic efficacy of 13-cis retinoic acid (13-cRA) in some subtypes of peripheral T-cell lymphoma (PTCL). This study sought to clarify if the addition of interferon-alpha2a (IFN-alpha2a), an agent with synergistic cytotoxicity with 13-cRA in many types of malignant cells, may be more effective in the treatment of PTCL. Eligible patients has histologically proven PTCL, which was recurrent after or refractory to anthracycline-containing systemic chemotherapy. The treatment included oral administration of 13-cRA 1 mg/kg/day, divided into three doses, and intramuscular injection of IFN-alpha2a 4.5 MU/M2, three times per week. From March 1995 to July 2000, a total of 17 patients, 10 men and 7 women, with a median age of 47 years (range, 18-77 years), were recruited. The histologic diagnosis included 7 cases of unspecified PTCL, 6 cases of Ki-1 anaplastic large cell lymphoma (ALCL), 1 case of angioimmunoblastic T-cell lymphoma, and 3 cases of angiocentric nasal NK/T cell lymphoma. They received a median of 1.7 months of treatment (range, 0.4-13.3 months). One patient refused further treatment due to toxicity. The doses of 13-cRA and IFN-alpha2a had to be decreased in 7 and 7 patients, respectively. Grade III/IV hematologic and non-hematologic toxicity developed in 2 and 5 patients, respectively. There were 5 partial responses (Ki-1, 4; unspecified PTCL, 1), with a total response rate of 31.3% (95% CI, 5.7-56.8%). The median duration of response for the responders was 2.5 months (range, 0.8-7.2 months). The median overall survival for the entire group of patients was 3.6 months. In conclusion, a combination of 13-cRA and IFN-alpha2a is a useful salvage treatment for selected patients with recurrent or refractory PTCL, particularly those with the Ki-1 subtype. However, the data does not support that addition of IFN-alpha2a is superior to 13-cRA alone.

Building a mouse model hallmarking the congenital human cytomegalovirus infection in central nervous system

To investigate the mechanisms that human cytomegalovirus (HCMV) can vertically transmit from the placenta of mice to infect their offspring in the central nervous system (CNS) and cause congenital anomalies, and in order to provide basic research for preparing HCMV vaccine, we have developed a new type of mouse model of HCMV congenital CNS infection. Pure strain mice were propagated after being infected with HCMV. Then the degree of infection by HCMV to offspring was determined. The experiment shows that in the infection groups the mortality of fetal mice and the fatality of neonatal mice in one week are higher than that of the control groups (P < or = 0.05). At the same time we investigated the CNS of fetus's mice whose mothers were infected by HCMV. Our results showed: 1. The virus was successfully isolated from their cerebral cortex. 2. The signal of HCMV hybridization print was found in their nervous cell through in situ hybridization. 3. Especially human herpes virus-like particles and inclusion bodies in the plasm of nerve cell were found in the tissue of their brain under the electron microscope. This new type of mouse model of HCMV inherent CNS infection will help prepare HCMV vaccine and research HCMV congenital infection in CNS.

High incidence of CD56 expression and relapse rate in acute myeloid leukemia patients with t(8;21) in Taiwan

BACKGROUND AND PURPOSE

CD56 is a marker of natural killer cells, but can also be found on blast cells in acute myeloid leukemia (AML). The prognostic implications of CD56 expression in AML are not clear. In this study, we evaluated the correlation among CD56 expression, cytogenetic abnormality, and clinical outcome in AML.

METHODS

CD56 expression was analyzed in leukemic cells from 94 adults with primary AML in Taiwan and was correlated with clinical and hematologic features, cytogenetics, and immunophenotypes of the leukemia.

RESULTS

Thirty patients (32%) showed CD56 expression. CD56+ AML patients had a higher lactate dehydrogenase level than CD56- patients (1.136 vs 730 V/L, p = 0.048). Patients with t(8;21) had a significantly higher incidence (89%, 8/9) of CD56 positivity in leukemic cells than those with normal karyotype or other cytogenetic abnormalities (26%, 22/85, p < 0.001). In general, there was no difference in overall survival time in CD56+ and CD56- AML patients. However, three patients had central nervous system involvement at initial presentation; two of these had concomitant CD56 expression and t(8;21). In addition, five of the seven patients with t(8;21) and CD56 expression who achieved complete remission later relapsed.

CONCLUSIONS

The incidence of CD56 expression in AML patients with t(8;21) is very high in Taiwan, and it may imply a poor prognosis in this subgroup of patients.

Marrow matrix metalloproteinases (MMPs) and tissue inhibitors of MMP in acute leukaemia: potential role of MMP-9 as a surrogate marker to monitor leukaemic status in patients with acute myelogenous leukaemia

Matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) were demonstrated to have important implications in the progression and invasiveness of many malignant disorders. In contrast, the biological significance of these molecules in human leukaemias is not clear. We determined the levels of MMP-2, MMP-9, TIMP-1 and TIMP-2 in the bone marrow of 37 patients with acute myelogenous leukaemia (AML) and 18 patients with acute lymphoblastic leukaemia (ALL) before chemotherapy. Nineteen bone marrow donors served as normal controls. After chemotherapy, sequential measurements were done during the course in 19 AML patients. The levels of TIMP-1 and TIMP-2 were significantly higher and MMP-9 levels were significantly lower in the AML and ALL patients than in the normal controls. MMP-2 levels were higher in ALL, but not AML patients, compared with controls. Moreover, the levels of marrow MMP-2 and MMP-9 did not parallel the numbers of leukaemic blasts in the peripheral blood. MMP-9 levels were significantly lower in the AML patients who achieved a complete remission (CR) than in those who did not (8.71 +/- 8.15 ng/ml vs 26.13 +/- 27.75 ng/ml, P < 0.05). The AML patients with lower MMP-9 levels (< or = 4.4 ng/ml) tended to have longer survival time than those with higher levels (> 12 months vs 4 months, P = 0.12). In addition, MMP-9 levels in the AML patients at CR rose to the same range as the controls, but dropped again at relapse, demonstrating a close relationship of marrow MMP-9 with disease status of AML. Therefore, we conclude that the level of marrow MMP-9 may be a useful surrogate marker for monitoring disease status in AML and propose it as a potential prognostic factor.

Applied anatomy of the V-shaped fibular osteomyocutaneous flap in reconstruction of the hindfoot

To establish the applied anatomy of the V-shaped fibular osteomyocutaneous flap pedicled on the peroneal vessels, cadaver dissections were made in 60 lower limbs and 40 calcanei were examined to sum up the features of calcaneal biomechanics on the stability of the foot and the blood supply of the fibular osteomyocutaneous flap. There were four anastomoses and large communicating branches between the lower segment of the peroneal artery and the anterior and posterior tibial arteries. The flap was well supplied by a retrograde circulation through these anastomoses. A suitable length of pedicle was 20 cm. In the sagittal section of the calcaneus passing through the center of the articular surface for the cuboid bone, the arrangement of the trabeculae formed a triangular zone. The V-shaped flap corresponds nicely with the calculated lines of stress evoked by the weight of the body. The procedure may provide a new method for hindfoot reconstruction. This flap meets the criteria outlined for composite tissue reconstruction of defects of the extremities and biomechanics of the hindfoot, especially for calcaneal and cuboid defects.

Osteogenic differentiation of mesenchymal stem cells derived from bone marrow of patients with myeloproliferative disorders

BACKGROUND

It has been frequently reported that culture-expanded mesenchymal stem cells from bone marrow of healthy donors can be induced to differentiate to osteocytic lineage. This study examined the potential for osteogenic differentiation of mesenchymal stem cells obtained from two patients with myeloproliferative disorders.

METHODS

Mesenchymal stem cells were derived from bone marrow aspirates obtained in an outpatient clinic from two patients, one with polycythemia vera and the other with essential thrombocythemia. Nucleated bone marrow cells were directly cultured in flasks. Adherent fibroblastic cells in monolayers were isolated by removing nonadherent cells during medium changes. Osteogenic differentiation was induced in expanded adherent cells for 2 weeks in osteogenic medium containing 100 nmol/L dexamethasone, 10 mmol/L beta-glycerophosphate, and 0.05 mmol/L L-ascorbic acid-2-phosphate. Osteogenic differentiation was evaluated by alkaline phosphatase staining and determination of calcium in deposited minerals on culture plates. The expression of osteopontin mRNA was determined by reverse transcription-polymerase chain reaction.

RESULTS

After induction in osteogenic medium, the expression of alkaline phosphatase in mesenchymal stem cells became more intense. Induced alkaline phosphatase-positive cells assumed an irregular shape with multiple spiculate projections, while uninduced alkaline phosphatase-positive cells had a flattened polygonal shape or were elongated. Calcium deposition on the plates of induced cells was 0.39 +/- 0.03 mumol/well in cells from the patient with polycythemia vera and 0.54 +/- 0.03 mumol/well in cells from the patient with essential thrombocythemia, but was not detectable in uninduced cells from either patient. Induction by osteogenic medium markedly increased the expression of osteopontin mRNA in stem cells derived from both patients.

CONCLUSIONS

In this study, mesenchymal stem cells obtained from aspiration of bone marrow in patients with myeloproliferative disorders were expanded by culture. After osteogenic induction, these cells were shown to be able to differentiate into osteocytic lineage in vitro.

The efficacy of thymosin in the treatment of chronic hepatitis B virus infection: a meta-analysis

BACKGROUND

Trials of thymosin treatment in chronic hepatitis B virus infection have been small and the results have been inconsistent.

AIM

To conduct a meta-analysis to evaluate the efficacy of thymosin treatment in chronic hepatitis B virus infection.

METHODS

Randomized controlled trials comparing thymosin for over 24 weeks vs. placebo (or usual care) in the treatment of chronic hepatitis B virus infection were identified through MEDLINE, EMBASE and the Cochrane Register of Clinical Trials. Biochemical (normalization of transaminases) and virological (loss of hepatitis B virus DNA and hepatitis B e antigen) responses were analysed using the intention-to-treat method. The odds ratio was used to measure the magnitude of the efficacy.

RESULTS

Five trials (353 patients) were identified. The odds ratio (95% confidence interval) of the virological response of thymosin over placebo at the end of treatment, 6 months post-treatment and 12 months post-treatment were 0.56 (0.2-1.52), 1.67 (0.83-3.37) and 2.67 (1.25-5.68), respectively. There was an increasing trend of the virological response with time since the cessation of thymosin treatment (P=0.02). There was no difference in the biochemical response between the thymosin and placebo groups at the end of treatment, 6 months post-treatment and 12 months post-treatment.

CONCLUSIONS

Thymosin is effective in suppressing viral replication in chronic hepatitis B virus infection, but the effect is delayed until 12 months after the cessation of treatment.