Post-transplantation lymphoproliferative disease in Chinese: the Queen Mary Hospital experience in Hong Kong

Post-transplantation lymphoproliferative disease (PTLD) is an unique iatrogenic complication after bone marrow transplantation (BMT) and solid organ transplantation (SOTx). The pattern of EBV related lymphoma in Chinese is different from Caucasians. We surveyed the incidence, clinical and pathological spectrum of PTLD among 541 cases of allogeneic BMT, 145 cases of renal transplant, 35 cases of heart/lung transplantation and 146 cases of orthotopic liver transplantation (OLT). From 1994 to 2001, 13 consecutive cases of PTLD were diagnosed, ranging from disseminated NK cell lymphoma to localized plasmacytoma. Both donor and recipient derived PTLD was documented. Disease was often heralded by cytomegaloviral disease and antithymocyte globulin (ATG) usage. Two cases were diagnosed post-mortem, and six patients died of PTLD at a median of 3 months. Complete and partial remission was only achieved in 3 and 2 cases, respectively, despite a range of treatment (reduced immunosuppression, explantation, radiotherapy, combination chemotherapy, donor lymphocytes, autologous marrow infusion and rituximab). Most responding patients died subsequently of rejection, infection and graft versus host disease (GVHD). The incidence of PTLD is not increased in Chinese patients. However, some patients may be at increased risk, especially mismatched allogeneic BMT, parental OLT (especially involving young infants) and heavy ATG exposure.

High field phase diagram of cuprates derived from the Nernst effect

Measurements of the Nernst signal in the vortex-liquid state of the cuprates to high fields (33 T) reveal that vorticity extends to very high fields even close to the zero-field critical temperature T(c0). In overdoped La2-xSrxCuO4, we show that the upper critical field H(c2)(T) curve does not end at T(c0), but at a much higher temperature. These results imply that T(c0) corresponds to a loss in phase rigidity rather than a vanishing of the pairing amplitude. An intermediate field H*(T)<<H(c2)(T) is shown to be the field scale for the flux-flow resistivity.

Combined arsenic trioxide and all-trans retinoic acid treatment for acute promyelocytic leukaemia recurring from previous relapses successfully treated using arsenic trioxide

The optimal treatment of acute promyelocytic leukaemia (APL) recurring from relapses successfully treated using arsenic trioxide (As2O3) is undefined. Three APL patients relapsing from As2O3-induced remission were studied. Re-treatment with As2O3 failed in one patient in third relapse, and resulted in morphological but not molecular remission in another patient. Combination therapy with As2O3 and all-trans retinoic acid (ATRA), however, resulted in morphological and molecular remission in all three cases, with a follow-up time ranging from 6 to 16 months. Our results suggest a synergistic therapeutic effect between As2O3 and ATRA in APL in advanced relapse.

Evidence for static magnetism in the vortex cores of ortho-II YBa2Cu3O6.50

Evidence for static alternating magnetic fields in the vortex cores of underdoped YBa2Cu3O6+x is reported. Muon spin rotation measurements of the internal magnetic field distribution of the vortex state of YBa2Cu3O6.50 in applied fields of H = 1 T and H = 4 T reveal a feature in the high-field tail of the field distribution which is not present in optimally doped YBa2Cu3O6.95 and which fits well to a model with static magnetic fields in the vortex cores. The magnitude of the fields is estimated to be 18(2) G and decreases above T = 10 K. We discuss possible origins of the additional vortex core magnetism within the context of existing theories.

Candida tropicalis fungaemia in adult patients with haematological malignancies: clinical features and risk factors

Candida tropicalis fungaemia is a serious opportunistic infection. Eighteen consecutive patients with C. tropicalis fungaemia diagnosed within a five-year period were studied retrospectively. All patients had haematological malignancies treated by chemotherapy or bone marrow transplantation (BMT). Antifungal prophylaxis included nystatin (20 mg daily) for patients receiving chemotherapy, and fluconazole (200 mg daily) for patients undergoing BMT. Sixteen patients had refractory and advanced haematological malignancies. All patients were neutropenic, had central venous catheters, and were receiving treatment with broad-spectrum antibiotics at the time of fungaemia. Septic shock with skin emboli were the most common presenting features. In seven cases, fungaemia was preceded by a positive culture of C. tropicalis in the urine. Concomitant bacteraemia was found in 11 cases, of which six cases were due to Staphylococcus aureus. The overall mortality rate was 56%. The predominance of chemotherapy-treated patients developing fungaemia in this series might be attributable to the omission of fluconazole prophylaxis. The clinicopathologic features and risk factors identified in this study may help design better treatment strategies for this often-lethal complication.

Association of homozygous 7048G7049 variant in the intron six of Nurr1 gene with Parkinson's disease

OBJECTIVE

To determine whether the Nurr1 gene, which is critical for the development and maintenance of nigral dopaminergic neurons, is a risk factor associated with PD.

BACKGROUND

The Nurrl gene is highly expressed in the dopaminergic neurons in the midbrain. Knockout of the gene results in agenesis of nigral dopaminergic neurons and heterozygous knockout mice increases 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced neurotoxicity.

METHODS

This study included 105 patients with familial PD (fPD) and 120 patients with sporadic PD (sPD) and 221 age-matched healthy control subjects. The polymorphisms and mutations of the Nurr1 gene in patients with PD were initially examined by heteroduplex analysis and sequencing analysis from PCR-amplified Nurr1 gene fragments. A polymorphism in the BseRI restriction site was identified, and a relatively large-scale analysis then was conducted by three independent investigators who were blinded to the clinical status of the subjects.

RESULTS

A homozygous 7048G7049 polymorphism was found in intron 6 of the Nurr1 gene, which was significantly higher in fPD (10/105; 9.5%) and in sPD (5/120; 4.2%) compared with healthy control subjects (2/221; 0.9%). The mean age and the SD at onset of these homozygote patients with PD was 52 +/- 15 years for fPD and 46 +/- 7 years for sPD. The clinical features of these homozygote patients with PD did not differ from those of typical PD.

CONCLUSIONS

The homozygote polymorphism of 7048G7049 in intron 6 of the Nurr1 gene is associated with typical PD.

Clinicopathological features and risk factors of clinically overt haemorrhagic cystitis complicating bone marrow transplantation

Haemorrhagic cystitis (HC) is an important complication after bone marrow transplantation (BMT). Overt HC (grade > or =2, gross haematuria, clot retention and impairment of renal function), clinically more important than mild and occult HC (grade 1, microscopic haematuria), leads to substantial morbidity and occasional mortality. We retrospectively analyzed 32 cases of clinically overt HC from a series of 236 BMT patients. Significant risk factors included the use of busulphan during conditioning, allogeneic BMT and acute GVHD. Logistic regression showed GVHD to be the most important risk factor. According to the time of engraftment, HC could be divided into pre- and post-engraftment subtypes. Pre-engraftment HC was brief, not more severe than grade 2, and subsided with supportive treatment. In contrast, post-engraftment HC was protracted, often of grade > or =3, associated with severe GVHD, and required surgical intervention in many cases. Polyoma BK viruria, but not adenoviruria, could be demonstrated in both types of HC. The increased severity and association with GVHD of post-engraftment HC suggested that attack of urothelium by immunocompetent cells, possibly directed against BK viral antigens, might play a pathogenetic role.

Glucose-6-phosphate dehydrogenase deficiency and hematopoietic stem cell transplantation

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked hemolytic enzymopathy affecting 3% of Southern Chinese males. Among 275 adult allogeneic hematopoietic stem cell transplantations (SCT), five cases (1.8%) each of donors and recipients were G6PD deficient. Among 107 autologous SCT, four patients (3.7%) were G6PD deficient. All subjects were male, except for two female patients with chronic myeloid leukemia (CML). The incidence of G6PD deficiency in female CML patients was significantly higher than the background female incidence (P = 0.004), but comparable with that in the males (P = 0.664). There was no significant hemolysis or delay in red cell engraftment, and all but one patient converted to donor G6PD screening status. One female patient achieved partial correction of her G6PD status and relapsed at 10 months. We suggest that G6PD deficiency should be tested for in all marrow donors and recipients in susceptible populations. From our data, there is a suggestion of increased clinical incidence of G6PD deficiency in female patients with multi-lineage clonal marrow disorders.

Speechless after bone marrow transplantation: a rare complication of parainfluenza virus related group in an adult

Upper respiratory tract (URT) viral infections may cause severe consequences during myeloablative bone marrow transplantation (BMT). We present a patient with parainfluenza virus (PIV) infection during the course of BMT. He remained relatively asymptomatic during the course of cytopenia, but presented with complete loss of voice and severe laryngitis a few days after engraftment, which is not usual for adult PIV infections. Seroconversion to PIV and marked increase in antibody titres was demonstrated, with complete lymphoid engraftment. Our case illustrated that the virulence of some URT viral infections depend on host immune factors, and may remain latent until graft versus host responses can be mounted.

Translation and validation of the Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT) Version 4 quality of life instrument into traditional Chinese

The need for a culturally sensitive instrument to assess quality of life (QOL) of patients in international oncology clinical trials has been well documented. This study was designed to evaluate the psychometric properties of the traditional Chinese translation (TCHI) of the Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT) Version 4. The FACT-BMT consists of the FACT-General and treatment-specific concerns of bone marrow transplantation. The Chinese translation follows the standard Functional Assessment of Chronic Illness Therapy (FACIT) translation methodology. Bilingual teams from the United States and Hong Kong reviewed the translation to develop a provisional TCHI FACT-BMT, which was then pre-tested by interviewing 20 native Chinese-speaking BMT patients in Hong Kong. The pre-test results indicated good content coverage and overall comprehensibility. A refined translation, taking into account patient comments, was validated by 134 BMT patients in Hong Kong. The results indicated the high internal consistency of the TCHI FACT-BMT scales, with Cronbach's alpha coefficients ranging from 0.71 (emotional well-being) to 0.92 (FACT-BMT total). The FACT-BMT also demonstrated good construct validity when correlated with SF-36 Health Survey scales. The QOL of Chinese BMT patients can now be evaluated using a well-validated international QOL instrument in their own language.

Aggressive hepatocellular carcinoma complicating pregnancy after autologous bone marrow transplantation for non-Hodgkin's lymphoma

In the Asia-Pacific region, autologous and allogeneic bone marrow transplantation (BMT) in patients infected with the hepatitis B virus (HBV) may be complicated by fatal hepatic failure due to viral reactivation. Survivors may suffer from accelerated hepatitis and cirrhosis. We report the first case of hepatocellular carcinoma (HCC) after autologous BMT for mediastinal B cell lymphoma. The tumor developed rampantly during a planned pregnancy 5 years after BMT. Less than 40 cases of HCC complicating pregnancy have been reported, and outcome is invariably poor. Immunosuppression and HBV reactivation after autologous BMT, as well as immune tolerance and hormonal changes associated with pregnancy may contribute to the rapid tumor growth. Biochemical and radiological surveillance for HCC should be strengthened in HBV carriers after BMT, especially in patients with the histology of chronic liver disease, or biochemical/ virological evidence of increased HBV activity.

A limit on spin-charge separation in high-Tc superconductors from the absence of a vortex-memory effect

There is a long-standing debate about whether spin-charge separation is the root cause of the peculiar normal-state properties and high superconducting transition temperatures of the high-Tc materials. In the proposed state of matter, the elementary excitations are not electron-like, as in conventional metals, but rather the electron 'fractionalizes' to give excitations that are chargeless spin-1/2 fermions (spinons) and charge +e bosons (chargons). Although spin-charge separation has been well established in one dimension, the theoretical situation for two dimensions is controversial and experimental evidence for it in the high-Tc materials is indirect. A model with sharp experimental tests for a particular type of separation in two dimensions has recently been proposed. Here we report the results of those experimental tests, placing a conservative upper limit of 190 K on the energy of the proposed topological defects known as visons. There is still debate about the extent to which this experiment can settle the issue of spin-charge separation in the high-Tc copper oxides, because some forms of the separation are able to avoid the need for visons. But at least one class of theories that all predict a vortex-memory effect now are unlikely models for the copper oxides.

Association of the HLA A2-B46-DR9 haplotype with autoimmune thyroid dysfunction after bone marrow transplantation in Chinese patients

Autoimmune thyroid disease (AITD) may occur in patients after bone marrow transplantation (BMT). At a median follow-up of 4 years, among 194 allografts and 28 autografts, four patients (three allografts, one autograft) developed AITD. All carried the human leucocyte antigen (HLA) A2-B46-DR9 haplotype, strongly associated with AITD in the Chinese population. No significant thyroid disorder was detected in 190 patients without this haplotype. The frequency of AITD in BMT patients with the HLA A2-B46-DR9 haplotype was 12.5%, with a relative risk of 7.8 times that of non-carriers (P < 0.001). The risk of AITD should be recognized in recipients with high-risk HLA haplotypes, and regular screening might be warranted.

Limits on spin-charge separation from h/2e fluxoids in very underdoped YBa2Cu3O(6+x)

Magnetic flux in superconductors is usually quantized in units of h/2e. Here we report scanning SQUID and scanning Hall probe studies of single fluxoids in high purity YBa2Cu3O6.35 crystals (T(c) less, similar 13 K), extending flux quantization studies to a region of the cuprate phase diagram where the superfluid density is sufficiently low that novel behavior has been predicted. Some scenarios in which superconductivity results from spin-charge separation predict h/e fluxoids in materials with low superfluid density. Our observations of only h/2e fluxoids set limits on these theories.

Risk of haematological malignancies in HLA-B27 carriers

Human leucocyte antigen (HLA)-B27 carriers are predisposed to inflammatory and autoimmune diseases. Among 1137 patients with haematological diseases, 59 HLA-B27 carriers were identified. Compared with 18 774 volunteers, the incidence of HLA-B27 was increased in patients with acute leukaemia (relative risk RR = 1.67, P = 0.002), for both acute myeloid leukaemia (AML) (RR) = 1.67, P = 0.007) and acute lymphoblastic leukaemia (ALL) (RR = 1.68, P = 0.094). Of all the HLA-B27 carriers, four patients had ankylosing spondylitis (AS), all with lymphoid malignancies (three ALL, one Hodgkin's disease), whereas no HLA-B27 carriers with myeloid leukaemia had AS symptoms (P = 0.006). This suggests that HLA-B27 carriers may have an increased risk of acute leukaemia and those with concomitant AS may be predisposed to lymphoid malignancies.

Genetic polymorphism in exon 4 of cytochrome P450 CYP2C9 may be associated with warfarin sensitivity in Chinese patients

CYP2C9 polymorphisms reported in Caucasians (Arg144Cys in exon 3 and Ile359Leu in exon 7) are extremely uncommon in Chinese persons. The genotype of CYP2C9 in this population was characterized to investigate its relation with the interindividual variation in warfarin dosages. Eighty-nine Chinese patients receiving warfarin were recruited. Target sequences in CYP2C9 in exons 1, 4, and 5 were amplified by polymerase chain reaction, followed by direct sequencing. Polymorphisms at 4 positions were demonstrated in exon 4. Heterozygosities for 608TTG>GTG (Leu208Val), 561CAG>CCG (Gln192Pro), 537CAT>CCT (His184Pro), and 527ATT>CTT (Ile181Leu) existed at frequencies 0.75, 0.20, 0.10, and 0.09, respectively. Seventeen patients (frequency, 0.19) were homozygous for Val208. The common genotypic combinations at these loci are Ile181/His184/Gln192/Leu208Val (n = 50), Ile181/His184/Gln192/Val208 (n = 15), Ile181/His184/Gln192/Leu208 (n = 4), Ile181/His184/Gln192Pro/Leu208Val (n = 6), Ile181/His184Pro/Gln192Pro/Leu208Val (n = 4), and Ile181Leu/His184/Gln192Pro/ Leu208Val (n = 4). At codon 208, heterozygous Leu208Val and homozygous Val208 appeared to have a lower warfarin dose requirement than the homozygous Leu208. Patients who are heterozygous for Ile181Leu had a higher warfarin dose requirement than the homozygous Ile181. Amplified sequences in exons 1 and 5 did not exhibit polymorphism. In conclusion, Chinese patients showed genetic polymorphisms of CYP2C9 in exon 4 and at codon 208; most were heterozygous Leu208Val and homozygous Val208. Homozygous Leu208, a common allele in Caucasians, is uncommon in this cohort. The significance of these CYP2C9 polymorphic alleles remains to be determined.

Determination of optical constants of thin films and multilayer stacks by use of concurrent reflectance, transmittance, and ellipsometric measurements

Using measurements of reflectance, transmittance, and the ellipsometric parameter D, we have determined the thickness, refractive index, and the absorption coefficient of various thin films and thin-film stacks. (D, the relative phase between the p- and s-polarized components, is measured for both reflected and transmitted light.) These optical measurements are performed with a specially designed system at the fixed wavelength of lambda = 633 nm over the 10 degrees -75 degrees range of angles of incidence. The examined samples, prepared by means of sputtering on fused-silica substrates, consist of monolayers and trilayers of various materials of differing thickness and optical constants. These samples, which are representative of the media of rewritable phase-change optical disks, include a dielectric mixture of ZnS and SiO(2), an amorphous film of the Ge(2)Sb(2.3)Te(5) alloy, and an aluminum chromium alloy film. To avoid complications arising from reflection and transmission losses at the air-substrate interface, the samples are immersed in an index-matching fluid that eliminates the contributions of the substrate to reflected and transmitted light. A computer program estimates the unknown parameters of the film(s) by matching the experimental data to theoretically calculated values. Although our system can be used for measurements over a broad range of wavelengths, we describe only the results obtained at lambda = 633 nm.

Blocking tumor growth, invasion, and metastasis by maspin in a syngeneic breast cancer model

Maspin is a unique serine protease inhibitor of which the down-regulation is associated with the development of breast cancers. In vitro, recombinant maspin inhibits tumor cell migration and invasion. Overexpression of maspin in transgenic mice is protective against tumor progression. Additionally, maspin acts as an angiogenesis inhibitor in rat cornea model and in a xenograft tumor model. To additionally prove that maspin is directly involved in the suppression of tumor growth and metastasis, we tested maspin in a new syngeneic mammary tumor model, TM40D. This model involves the implantation of TM40D mammary tumor cells orthotopically to the mammary gland; tumors grew within the gland and then become invasive and metastatic to other organs. Here we demonstrate that TM40D cells in implanted mammary glands are highly invasive. Overall, a 75% rate of invasion and metastasis was observed in this model. However, both primary tumor growth and metastasis were significantly blocked in TM40D cells that overexpress maspin as a consequence of plasmid or retrovirus infection. Maspin-transfected tumors tended to have tumor encapsulation and less necrosis, which were associated with better prognosis and lower invasiveness. Thus, maspin can block primary tumor growth as well as invasion and metastasis. These data support the concept that maspin has a strong protective role against tumor progression.

[Clinical application of ultrasonographic indexes for assessment of amniotic fluid volume]

OBJECTIVE

To find the favorable interval of assessment of amniotic fluid volume and the optimal standard for oligohydramnios.

METHODS

To determine actual amniotic fluid volume (AAFV) by collecting amniotic fluid during cesarean section and compare it with maximum vertical pocket (MVP) and amniotic fluid index (AFI) in different interval between cesarean section and measurement and test the sensitivity and specificity of MVP and AFI of different standard.

RESULTS

The ultrasonographic results were divided into three groups according to the interval between measurement and delivery: within 24 hours group, 24-96 hours group and longer than 96 over hours group. The results of the within 24 hours and 24-96 hours groups were positively correlated with AAFV, while the results of the group longer than 96 hours were not statistically significant. The correlation coefficients were 0.840 and 0.869 for MVP, 0.789 and 0.874 for AFI respectively. The receiver-operator characteristic curve showed that MVP < 4 cm and AFI < 10 cm were superior to any other standards to scan oligohydramnios. The sensitivity of these standards was 0.76 and 0.61, and the specificity was 0.83 and 0.91.

CONCLUSION

It is highly recommended to estimate the amniotic fluid of high risk pregnant women, women with MVP < 4 cm or AFI < 10 cm and with a pregnancy week > 40 weeks should be monitered by ultrasonography every four days.

Hepatitis B virus (HBV) reactivation after cytotoxic or immunosuppressive therapy--pathogenesis and management

In an endemic area for chronic hepatitis B infection, reactivation of this virus is a serious cause of morbidity and mortality in patients undergoing cytotoxic or immunosuppressive therapy. Careful prospective serological testing has shown that hepatitis B virus reactivation is a two-staged process. The initial stage occurs during intense cytotoxic or immunosuppressive therapy and is characterised by enhanced viral replication, as reflected by increases in the serum levels of hepatitis B virus DNA, hepatitis B e antigen, hepatitis B virus DNA polymerase and infection of naïve hepatocytes with hepatitis B virus. The second stage is related to restoration of immune function following withdrawal of cytotoxic or immunosuppressive therapy, which causes rapid immune-mediated destruction of infected hepatocytes. Clinically, this can lead to hepatitis, hepatic failure and even death. The occurrence and severity of hepatitis B virus reactivation after various cytotoxic or immunosuppressive therapy is unpredictable and treatment has been disappointing, largely due to the late administration of therapy. Recently, pre-emptive treatment of chronic hepatitis B patients undergoing cytotoxic or immunosuppressive therapy, with potent nucleoside analogues has shown some promising results. Further controlled studies are needed to define the incidence and risk factors of hepatitis B reactivation so that pre-emptive treatment with nucleoside analogues could be administered to those patients at high risk of disease.

Plasma nitric oxide is associated with the occurrence of moderate to severe acute graft-versus-host disease in haemopoietic stem cell transplant recipients

BACKGROUND AND OBJECTIVES

Nitric oxide (NO) has been implicated as one of the mediators of acute graft-versus-host disease (GVHD) but reports on its measurement during haemopoietic stem cell transplantation (HSCT) in human are scarce. The present study was conducted to measure the plasma NO in HSCT recipients in order to delineate its relationships with acute GVHD.

DESIGN AND METHODS

Thirty-nine randomly selected patients undergoing HSCT were recruited. Thirty-one patients received allogeneic transplants (ALLO) from HLA-identical siblings (n=20), haploidentical parent (n=1) and matched unrelated donors (n=10). Eight patients received autologous (AUTO) HSCT. Plasma levels of nitrite/nitrate (NO(2)(-)/NO(3)(-)), the end-product of NO, were measured by chemiluminescence and the results were correlated with the occurrence and severity of acute GVHD.

RESULTS

Baseline NO(2)(-)/NO(3)(-) levels before HSCT were similar in the ALLO and AUTO patients (17.4 vs 21.1 microL, p>0.05). Significant increases in plasma NO(2)(-)/NO(3)(-) (> 2 times the baseline level) were found in all 13 patients with acute GVHD > or = grade 2, in 15 out of 18 patients with acute GVHD grade < or = 1 and 3 out of 8 patients receiving autologous HSCT. The increase in NO(2)(-)/NO(3)(-) among the three groups of patients was significantly different (135.5 vs 56.3 vs 36.6 micromol/L, p < 0.001). The average NO production, calculated as the area under the curve, was also significantly differently among the three groups of patients (44.5 vs 30.0 vs 23.8 micromol/L, p < 0.001).

INTERPRETATION AND CONCLUSIONS

Plasma NO in HSCT recipients is quantitatively associated with the occurrence of acute GVHD and its role remains to be determined.