P6226Association of functional iron deficiency with incident cardiovascular diseases and mortality in the general population

Background

Functional iron deficiency (FID) has been established as a risk factor in patients with cardiovascular diseases (CVD). As opposed to absolute iron deficiency, it reflects stored iron as well as utilized iron and allows for a more accurate evaluation of individual iron status. However, evidence is scant on the relevance of FID to the incidence of CVD in the general population.

Aim

This study aimed to evaluate the association of FID with incident cardiovascular diseases and mortality endpoints in a large population-based cohort.

Methods

FID was defined as either ferritin below 100 μg/L or ferritin between 100 and 299 μg/L and transferrin saturation below 20%. Only individuals free of CVD at baseline from three population-based European cohorts were included. Multivariable-adjusted sex- and cohort-stratified Cox regression analyses were performed to evaluate the association of functional iron deficiency with incident cardiovascular diseases (coronary heart disease, cerebral infarction, heart failure and atrial fibrillation) as well as with all-cause and cardiovascular mortality. Adjustments were performed for sex (as strata), age (as time scale), smoking, total cholesterol, systolic blood pressure, diabetes, body mass index and high-sensitive C-reactive protein.

Results

In total, N=12146 individuals were included in the analysis with a median age of 59.0 years (25thpercentile 45.0, 75thpercentile 68.0), and 45.2% men. Incidence of FID was 64.3%. Median follow-up times were 12.3 to 21.8 years, with an all-cause mortality rate of 18.2% and a cardiovascular mortality rate of 6.2%. Incident coronary heart disease, cerebral infarction, heart failure and atrial fibrillation were observed in 8.7%, 6.5%, 5.9% and 11.7%, respectively.

FID was significantly associated with all-cause mortality (hazard ratio (HR) 1.12, 95% confidence interval (CI) 1.01–1.24, p=0.034), cardiovascular death (HR 1.26, 95% CI 1.03–1.54, p=0.027) and incident coronary heart disease (HR 1.23, 95% CI 1.06–1.43, p<0.01). There was no significant association with the other tested endpoints.

Conclusion

In our analysis of population-based cohorts, FID showed a significant positive association with all-cause as well as cardiovascular mortality and incident coronary heart disease. Further research is needed to validate the role of FID as a cardiovascular risk factor in the general population and to evaluate the impact of iron supplementation on gender and outcome.

Autologous haematopoietic stem cell transplantation: a viable treatment option for CIDP

OBJECTIVE

Only 70-80% of patients with chronic inflammatory demyelinating polyneuropathy (CIDP) respond satisfactorily to the established first-line immunomodulatory treatments. Autologous haematopoietic stem cell transplantation (AHSCT) has been performed as a last treatment resort in a few therapy-refractory cases with CIDP. We describe the results of AHSCT in 11 consecutive Swedish patients with therapy-refractory CIDP with a median follow-up time of 28 months.

METHOD

Case data were gathered retrospectively for AHSCT treatments in 11 patients with CIDP refractory to the first-line immunomodulatory treatments, intravenous high-dose immunoglobulin, corticosteroids and plasma exchange and to one or more second-line treatments used in 10 of the 11 patients.

RESULTS

The median Inflammatory Neuropathy Cause and Treatment (INCAT) score within 1 month prior to AHSCT was 6 and the Rankin score 4. Total INCAT and Rankin scores improved significantly within 2-6 months after AHSCT and continued to do so at last follow-up. The motor action potential amplitudes (CMAP) improved already within 4 months (median) after AHSCT. Three of the 11 patients relapsed during the follow-up period, requiring retransplantation with AHSCT in one. Eight of the 11 patients maintained drug-free remission upon last follow-up. AHSCT was safe but on the short term associated with a risk of cytomegalovirus (CMV) and Epstein-Barr virus reactivation, CMV disease, haemorrhagic cystitis and pancreatitis.

CONCLUSIONS

Our results though hampered by the limited number of patients and the lack of a control group suggest AHSCT to be efficacious in therapy-refractory CIDP, with a manageable complication profile. Confirmation of these results is necessary through randomised controlled trials.

Synergy effects of HbA1c and variants of APOE and BDNFVal66Met explains individual differences in memory performance

We aimed at exploring if synergy effects of Brain-Derived Neurotrophic Factor (BDNF) Val(66)Met, Apolipoprotein E (APOE) and HbA1c (glycated haemoglobin) could explain individual differences in memory performance over 10 years in a population based sample of nondemented adults (N=888, 35-85 years at baseline). Episodic memory was affected by such agents, wheras semantic memory was spared. Both age and HbA1c were associated with episodic memory decline. BDNF(66)Met carriers with higher HbA1c levels evidenced slope decline in episodic recall. We found support for joint effects of BDNFVal(66)Met×APOE×HbA1c and BDNFVal(66)Met×APOE×age on rates of episodic memory change over ten years, after controlling for age, sex, education and cardiovascular diseases. We conclude that variants of genetic polymorphisms act in synergy with long-term blood glucose control in shaping patterns of cognitive aging.

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

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

Health education improves both arthritis-related illness and self-rated health: an intervention study among older people in rural Bangladesh

OBJECTIVES

To examine changes in self-reported arthritis-related illness and self-rated health as a result of a health education intervention, and the association between self-reported arthritis-related illness and self-rated health.

STUDY DESIGN

A quasi-experimental study was conducted in eight randomly selected villages in rural Bangladesh (intervention = 4; control = 4).

METHODS

The intervention consisted of home-based physical activities, health advice and aspects of healthcare management over 15 months followed by a 3-month latent period. Data were collected before the intervention and after the latent period. Analyses included 839 participants (≥60 years of age) who participated in both surveys. Participants in the intervention area were further categorized into two groups who self-reported compliance or non-compliance with recommended health advice. Self-rated health was assessed using a single global question. Self-reported arthritis-related illness was indicated by the presence of arthritis, back and joint pain, biting sensation, swelling and inflammation in the joints.

RESULTS

Hierarchical logistic regression analyses revealed that positive effects on episodes of arthritis-related illness [odds ratio (OR) 1.9, 95% confidence interval (CI) 1.3-2.8] and self-rated health (OR 1.4, 95% CI 1.0-1.9) were more likely among the compliant group compared with the control group. Furthermore, positive self-rated health was more likely among participants reporting a positive change in their arthritis-related illness (OR 2.2, 95% CI 1.5-3.2). The results also showed that literate and non-poor participants were more likely to report positive health, and participants with advancing age were less likely to report positive health.

CONCLUSION

Community-based health education is effective in reducing the burden of arthritis-related illness and in enhancing general health in old age.

Allogeneic haematopoietic stem-cell transplantation with reduced intensity conditioning for advanced stage Hodgkin's lymphoma in Sweden: high incidence of post transplant lymphoproliferative disorder

Allogeneic transplantation after reduced intensity conditioning (allo-RIC) is a treatment option for patients with Hodgkin's lymphoma (HL) relapsing after autologous transplantation. In all, 23 adult patients with HL underwent allo-RIC in Sweden between 2000 and 2007. The median number of previous treatment lines was five and 20 patients (87%) were previously autografted. TRM at 100 days and at 1 year was 13 and 22% respectively. Acute GVHD grades II-IV developed in 7 out of 23 patients (30%) and chronic GVHD in 10 out of 20 patients at risk (50%). The OS and EFS at three years was 59 and 27%, respectively. Four patients (17%) developed post transplant lymphoproliferative disease (PTLD) after a median time of 55 days (range 38-95); two of these patients later died. The study confirmed that allo-RIC is feasible, but associated with a substantial relapse rate: only 20% of the patients were still alive 7 years after the transplant. A finding of high incidence of PTLD needs to be confirmed in a larger trial that includes patients with non-HL and CLL.

Renal concentrating capacity in long-term lithium treatment and after withdrawal of lithium

The urinary concentrating capacity was estimated with the DDAVP test in 87 patients receiving lithium therapy, which was discontinued in all patients. The test was repeated three and eight weeks after withdrawal of lithium in 75 patients and one year after withdrawal in 27 patients. Of the 87 patients, 52 were also treated with neuroleptics, which treatment was continued throughout the study. Two control groups, consisting of 30 patients receiving only neuroleptics and 30 healthy subjects, were studied on one occasion with the DDAVP test. Lithium-treated patients had significantly lower concentrating capacity and higher serum creatinine than healthy subjects at all examinations. Small but statistically significant correlations were found between urinary osmolality and total dose of lithium, between urinary osmolality and duration of lithium treatment, between the highest serum lithium concentration recorded and urinary osmolality after withdrawal of lithium and between the daily dose of lithium and urinary osmolality, while patients were still on lithium. The concentrating capacity improved significantly during the first two months after withdrawal of lithium, but not later. One year after withdrawal of lithium, 17 of 27 patients still had a concentrating capacity below 800 mOsm/kg. Patients receiving lithium and neuroleptics had lower concentrating capacity than patients treated with lithium alone, and patients treated with neuroleptics alone had lower concentrating capacity than healthy subjects.

Improved survival in multiple myeloma with renal failure

Forty-four myeloma patients with large tumour cell mass and impairment of renal function (S-creatinine greater than 2 mg/dl, stage III B) were studied. Seven patients, who received no active treatment, neither cytostatics nor plasmapheresis, survived for less than 1 month (median). Twenty-one patients who were treated with chemotherapy combination (M-2 protocol: melphalan, vincristine, BCNU, cyclophosphamide, prednisone) plus plasma exchanges for three days at the start of each 5-week cycle survived longer (median 17 months, p less than 0.01) than 16 patients who were treated with melphalan-prednisolone alone (median 2 months). However, better supportive care, dialysis, and improved antibiotic treatment may also have contributed to the improved results. It is concluded that intensive chemotherapy in full dosage, plasmapheresis, and active uremia treatment including dialysis should be considered in patients with advanced myeloma and renal failure.

The urinary sediment in hydronephrosis

Phase contrast microscopy has been used for examination of urinary sediments from 19 patients with hydronephrosis. Casts were seldom seen. A raised number of erythrocytes was seen only in association with catheter, calculi or diabetes. A raised number of leukocytes was seen in patients with bacteriuria. A striking observation was the finding of a great proportion (64%) of histiocyte-like cells in six out of 12 cases in whom a differential count was performed. The proportion of histiocyte-like cells was small (14%) in cases with bacteriuria or history of urinary tract infection.

ECG changes during lithium therapy. A prospective study

The influence of long-term lithium treatment on the ECG was investigated in 53 consecutive patients. An ECG was recorded prior to and 4 and 12 months after institution of lithium therapy. The most frequently observed change during treatment was flattening or inversion of the T wave. Heart rate decreased and P-Q interval increased slightly during therapy. There was no change in the S-T segment or the Q-T interval corrected for heart rate. Our data indicate that well monitored lithium treatment of patients with serum lithium concentrations of about 0.6 mmol/l does not cause serious ECG abnormalities. In the absence of symptoms or signs of heart disease, routine monitoring of ECG is not necessary during lithium treatment.

Response to busulphan treatment of paroxysmal nocturnal hemoglobinuria and myelofibrosis in one and the same patient

Paroxysmal nocturnal hemoglobinuria (PNH) occurs occasionally in association with other blood disorders. This fact has led to the suspicion, that a mutation on the stem cell level may produce a dual defect of hematopoiesis, the PNH defect as well as other disturbances in blood formation. A patient with PNH and myelofibrosis appearing simultaneously is presented. Treatment with busulphan resulted in reduction of the hemolysis and improvement of the patient's condition. To our knowledge, this experience has not been described previously.

Renal function and morphology in long-term lithium and combined lithium-neuroleptic treatment

Ten patients on long-term lithium therapy and ten on lithium and neuroleptics (combination therapy) were examined with renal biopsy and tests of renal function. Patients on combination therapy had more pronounced histopathological changes and lower concentrating capacity than patients on lithium alone. Patients on combination therapy had received a larger total dose of lithium and had had higher maximum serum lithium levels than patients on lithium alone. Patients with large daily urine volumes had a low concentrating capacity. There was a negative correlation between degree of histopathological lesions and urinary concentrating capacity. Estimation of urinary concentrating capacity seems to be of value for the assessment of renal lesions in lithium treatment.

Renal function in familial amyloidosis with polyneuropathy

The renal function is assumed to be normal in most patients with familial amyloidosis with polyneuropathy (FAP) type 1. In the present study of 24 patients with FAP type 1, estimation of the urinary concentrating capacity and 51Cr-EDTA clearance demonstrated that the glomerular clearance and the concentrating capacity were imparied in most patients. The concentrating capacity was significantly correlated with the clearance values. Urine electrophoresis indicated a glomerular cause for the proteinuria. It is suggested that the renal dysfunction should be attributed to deposition of amyloid substance in the glomeruli.

Failure of chlorothiazide to improve urinary concentrating capacity in lithium-treated patients

Seven patients on long-term lithium treatment were given chlorothiazide for three days. The urinary concentrating capacity did not change during the study, but serum potassium decreased significantly. Thus, chlorothiazide does not seem to produce an effect on a moderately decreased concentrating capacity during long-term lithium treatment.

Staging of idiopathic myelofibrosis. Significance of haemoglobin value and reticulocyte count

A retrospective analysis of 18 patients with idiopathic myelofibrosis (IMF) suggested that IMF is adequately staged by combining haemoglobin value and reticulocyte count. Four stages were recognized. All deaths occurred in late stage. The stages appeared to reflect a sequential course of the disease. The present staging system adequately identified patients at high risk. However, the rate of disease progress varied greatly. It is therefore suggested that the rate of disease progress should also be considered when an individual patient is evaluated.

Evaluation of serial bone X-ray examination in multiple myeloma

Fifteen patients with multiple myeloma stage III were treated with a combination of cytostatics and plasmapheresis in a sequential trial running for 60 weeks. Thirteen patients showed clinical improvement and ten a reduction of their myeloma protein by at least 50%. Bone X-ray examination was performed every 15 weeks. Progression of bone lesions was seen in one patient, whereas the radiographic picture was unchanged in the others. It is concluded that bone X-ray, although essential in the diagnosis and staging of multiple myeloma, is not suitable for the monitoring of patients during treatment.

Myeloma-associated cardiac amyloidosis. A case report

A patient with Bence-Jones myeloma and amyloidosis was treated with cytotoxic drugs and plasmapheresis, resulting in rapid improvement of myeloma-associated symptoms and signs. However, amyloidosis-associated symptoms, especially hypotension, grew worse. Echocardiographic examination demonstrated hypertrophy and a hyperrefractile appearance of the myocardium, thought to be pathognomonic of amyloid heart disease. A permanent pacemaker was inserted for treatment of Adams-Stokes attacks caused by sick sinus syndrome and atrioventricular conduction disturbances. Postmortem examination of the heart demonstrated abundant amyloid deposits corresponding to the altered acoustic qualities of the myocardium. Echocardiographic examination is a valuable non-invasive method for demonstration of amyloid deposits in the heart in multiple myeloma.

Effects of plasmapheresis on the plasma concentration of proteins used to monitor the disease process in multiple myeloma

We studied the influence of plasmapheresis on the plasma concentrations of proteins (IgG, IgA, beta 2-microglobulin) used for estimation of tumour cell mass in patients with multiple myeloma. Simultaneously, the effects of plasmapheresis on plasma concentrations of proteins (CRP, alpha 1-antitrypsin, haptoglobin) used for the assessment of inflammatory processes were studied. Also, changes in the plasma concentration of protein HC, a recently described protein occurring both as a free protein and as an IgA complex, were studied. The influence of plasmapheresis varied for the different proteins. The plasma levels of IgG, IgA, CRP, alpha 1-antitrypsin, and haptoglobin decreased during plasmapheresis. The simultaneous reduction of the level of protein HC was smaller than that of IgG, IgA and haptoglobin. The plasma concentration of beta 2-microglobulin did not decrease during plasmapheresis. The recovery rates of the proteins were found to be approximately inversely related to their molecular weights.

Identification of renal tubular epithelial cells in urine with immunofluorescence

Rabbits were immunized with human kidney homogenate. The rabbit sera, after absorption with human liver homogenate, showed antibody activity against human kidney, renal pelvis and urinary bladder. The sera were then absorbed with human renal pelvis and urinary bladder mucosa and subsequently showed no antibody activity against urinary bladder or renal pelvis. Immunofluorescence examinations showed fluorescing cells in kidney tubules, but not elsewhere. The finally absorbed antihuman kidney sera were used for indirect immunofluorescence examination of urinary sediments from patients with renal disease. Phase contrast microscopy was used simultaneously. Fluorescence was found in cells which in phase contrast microscopy were judged to be renal tubular cells. Fluorescing cells were often found in casts, but free cells were also seen. Immunofluorescence may thus provide a means of identifying renal tubular cells in urine.

The impact of health education in managing self-reported arthritis-related illness among elderly persons in rural Bangladesh

This study examines the impact of health education on prevalence of and expenditure on treatment of self-reported arthritis-related illness among elderly persons in rural Bangladesh. An intervention study was conducted, including 1135 elderly persons (>or=60 years) from eight randomly selected villages, four each of an intervention and a control area. The analyses include 839 elderly persons who participated in both pre- and post-intervention surveys (intervention area: n = 425, control area: n = 414). Participants of the intervention area were further categorized as compliant (n = 315) and non-compliant (n = 110) based on adherence to the intervention instructions. The intervention that lasted for 15 months comprised home-based physical exercise, dietary instructions and other aspects of management. Results show that although there was no significant difference in self-reported arthritis-related illness between the compliant and non-compliant groups at baseline, it was significantly lower in the compliant group (71%) at post-intervention compared with the non-compliant (81%). Related monthly expenditure on treatment was significantly reduced in the compliant group (from Taka 104 to Taka 52) but not in the other two groups. Logistic regressions further showed that the control group had a higher probability of increased treatment-related expenditure compared with the compliant group (OR 2.0, 95% CI 1.4-2.8).

Low episodic memory performance as a premorbid marker of depression: evidence from a 3-year follow-up

OBJECTIVE

To examine low episodic memory scores as a potential risk factor for depression.

METHOD

A population-based sample of non-depressed individuals (20-64 years) were re-examined 3 years after an initial screening (n = 708). At baseline, information on episodic memory scores, demographic and socioeconomic factors, alcohol use and anxiety diagnoses was collected. The data for depression diagnoses were collected at both baseline and follow-up.

RESULTS

Logistic regressions, conducted on three separate study groups that were defined according to three assessments of episodic memory (i.e. free + cued recall, free recall, cued recall) among individuals who scored in the 25 lowest or highest percentiles in the memory tests, revealed that low episodic memory performance defined as the sum of free and cued recalls of organizable words constitutes a risk of depression diagnosis 3 years later.

CONCLUSION

Low episodic memory performance predated depressive diagnosis and might be considered as a premorbid marker of depression.

Attitude towards remission induction for elderly patients with acute myeloid leukemia influences survival

Combination chemotherapy may induce remission from acute myeloid leukemia (AML), but validated criteria for treatment of elderly are lacking. The remission intention (RI) rate for elderly patients, as reported to the Swedish Leukemia Registry, was known to be different when comparing the six health care regions, but the consequences of different management are unknown. The Leukemia Registry, containing 1672 AML patients diagnosed between 1997 and 2001, with 98% coverage and a median follow-up of 4 years, was completed with data from the compulsory cancer and population registries. Among 506 treated and untreated patients aged 70-79 years with AML (non-APL), there was a direct correlation between the RI rate in each health region (range 36-76%) and the two-year overall survival, with no censored observations (6-21%) (chi-squared for trend=11.3, P<0.001; r2=0.86, P<0.02, nonparametric). A 1-month landmark analysis showed significantly better survival in regions with higher RI rates (P=0.003). Differences could not be explained by demographics, and was found in both de novo and secondary leukemias. The 5-year survival of the overall population aged 70-79 years was similar between the regions. Survival of 70-79-year-old AML patients is better in regions where more elderly patients are judged eligible for remission induction.

Differential effects of estrogen on DNA synthesis in human periodontal ligament and breast cancer cells

BACKGROUND

It is important to clarify the biological function of the female sex hormones estrogen and progesterone in periodontal ligament cells, as these hormones may affect periodontal health. We have previously shown that human periodontal ligament cells express estrogen receptor beta (ERbeta) but not ERalpha, whereas human breast cancer cells (MCF7) express both ERalpha and ERbeta. Data on progesterone receptor (PgR) expression in human periodontal ligament cells have not been reported.

OBJECTIVES

Determine PgR expression in human periodontal ligament and MCF7 cells and to investigate how estrogen affects DNA and collagen synthesis in these two cell types showing different pattern of expression for ERalpha and beta.

METHODS

Periodontal ligament cells were obtained from the periodontal ligament of premolars extracted for orthodontic reasons and MCF7 cells from the American Type Culture Collection (ATCC). PgR expression was determined by immunocytochemistry. DNA and collagen synthesis was determined by [(3)H]thymidine and L-[(3)H]proline incorporation, respectively.

RESULTS

PgR immunoreactivity was observed in nuclei of MCF7 but not periodontal ligament cells. Treatment with estrogen (17beta-estradiol, E(2)) at physiological concentrations for 24 h stimulated DNA synthesis by more than two times in MCF7 cells, whereas there was no effect on periodontal ligament cell DNA synthesis. The ER blocker ICI 182780 fully reversed the stimulatory effect of E(2). Not only short-term (24 h) but also long-term (5 days) treatment with E(2) lacked effect on DNA synthesis in periodontal ligament cells. Neither periodontal ligament cell viability nor collagen synthesis was affected by E(2) treatment. Identical results were observed in periodontal ligament cells from male and female subjects.

CONCLUSIONS

Human MCF7 but not periodontal ligament cells express PgR, suggesting that progesterone via PgR affects MCF7 but not periodontal ligament cells. Further, estrogen stimulates breast cancer MCF7 cell proliferation, whereas it has no effect on proliferation of periodontal ligament cells, probably reflecting cell type specific ER expression pattern in these two cell types.

Diabetes mellitus and risk of dementia in the Kungsholmen project: a 6-year follow-up study

BACKGROUND

Research on diabetes mellitus as a risk factor for dementia and its main subtypes has produced conflicting results. The authors investigated the relationship between diabetes mellitus and risk of dementia, Alzheimer disease (AD), and vascular dementia (VaD).

METHODS

A dementia-free cohort of 1,301 community dwellers aged 75 years and older in Stockholm, Sweden, was longitudinally examined twice over 6 years to detect dementia cases (Diagnostic and Statistical Manual of Mental Disorders-III-R diagnostic criteria). Cox proportional hazards models were used to analyze the data with adjustment for several potential confounders.

RESULTS

During the 5,584 person-years of follow-up, 350 subjects developed dementia, including 260 AD and 49 VaD cases. Diabetes mellitus was associated with hazard ratios (HR) of 1.5 (95% CI 1.0 to 2.1, p = 0.04) for dementia, 2.6 (95% CI 1.2 to 6.1) for VaD, and 1.3 (95% CI 0.9 to 2.1) for AD. Patients who were treated with oral antidiabetic medications had HRs of 1.7 (95% CI 1.0 to 2.8, p = 0.04) for dementia and 3.6 (95% CI 1.3 to 9.5) for VaD. There were significant interactions of diabetes with severe systolic hypertension (> or =180 mm Hg) on dementia and its main subtypes, and of diabetes with heart disease on VaD.

CONCLUSIONS

Diabetes mellitus increases the risk of dementia, and VaD in particular, in very old people. The risk for dementia and VaD is especially high when diabetes mellitus occurs together with severe systolic hypertension or heart disease.

Autologous and allogeneic stem cell transplantation in adult ALL: the Swedish Adult ALL Group experience

Adult patients with acute lymphoblastic leukaemia (ALL) have been treated according to national protocols in Sweden since 1986. Stem cell transplantation (SCT) has been recommended in first remission for patients with risk factors for relapse, and for standard risk patients only after relapse. In this retrospective study, the results of autologous and allogeneic SCT in these populations were evaluated. In total, 187 patients with a median age of 34 years (17-66 years) underwent SCT. The 5-year disease-free survival (DFS), for all patients, was 26% (Confidence intervals (CI) 20-32%). The 5-year DFS was higher for patients transplanted in first remission 32% (CI 24-40%) compared to 14% (CI 5-23%; P<0.0001) in patients transplanted beyond first remission. No significant differences in DFS (P=0.06) were determined between autologous, related donor and unrelated donor SCT in the whole cohort. A lower relapse rate was counterbalanced by higher treatment-related mortality in patients undergoing allogeneic SCT. In Philadelphia-positive ALL, allogeneic SCT was superior to autologous SCT, with a 5-year DFS of 30% (CI 12-47%) vs 0% (P=0.04). Limited chronic graft-versus-host-disease (GVHD) was associated with an improved DFS of 53% (CI 38-69%) compared to no chronic GVHD of 22% (CI 10-36%; P=0.0008), indicating a clinically important graft-versus-leukaemia effect.

Haematopoetic stem cell transplantation for refractory autoimmune cytopenia

This study describes the outcome of patients receiving haematopoietic stem cell transplantation (HSCT) to treat severe refractory autoimmune cytopenia. The registry of the European Group of Blood and Marrow Transplantation holds data on 36 patients receiving 38 transplants, the first transplant was autologous for 27 and allogeneic for nine patients. Patients had autoimmune haemolytic anaemia (autologous: 5; allogeneic: 2), Evans's syndrome (autologous: 2; allogeneic: 5); immune thrombocytopenia (autologous: 12), pure red cell aplasia (autologous: 4; allogeneic: 1), pure white cell aplasia (autologous: 1; allogeneic 1), or thrombotic thrombocytopenic purpura (autologous: 3). Patients had longstanding disease having failed multiple prior treatments. Among 26 evaluable patients mobilized for autologous HSCT, three died of treatment-related causes, one died of disease progression, seven were non-responders, six patients had transient responses and nine had continuous partial or complete remission. Of the seven evaluable patients receiving allogeneic HSCT, one died of treatment-related complications, one with transient response died of progressive disease and five had a continuous response. Autologous and allogeneic HSCT may induce a response in a subset of patients with autoimmune cytopenia of long duration albeit at the price of considerable toxicity.

More efficient mobilisation of peripheral blood stem cells with HiDAC+AMSA+G-CSF than with mini-ICE+G-CSF in patients with AML

We have compared the efficacy of two PBSC mobilisation regimens, mini-ICE+filgrastim (second consolidation) and HiDAC+AMSA+filgrastim (third consolidation), in two consecutive cohorts of patients with AML CR1 receiving treatment according to a joint protocol. Group A: 18 patients, aged 41 (21-65) years, were mobilised with mini-ICE (idarubicin 8 mg/m(2)+cytarabine 800 mg/m(2)+etoposide 150 mg/m(2) days 1-3) followed by filgrastim 300-480 microg once daily s.c. from day 11 after start of chemotherapy. Only four patients reached >5 CD34+ cells/microl blood (B-CD34+) and were able to undergo leukaphereses. Two out of 18 (11%) reached the defined target of >/=2.0 x 10(6) CD34+ cells/kg after 1-3 leukaphereses. Group B: 20 patients, aged 50 (29-67) years, received HiDAC+AMSA (cytarabine 3 g/m(2) b.i.d. days 1, 3, 5+amsacrine 150 mg/m(2) q.d. days 2, 4) followed by filgrastim at a similar dose starting on day 7. A total of 18 patients reached B-CD34+ >5/microl and underwent PBSC harvesting, starting on day 23 (14-29) and yielding 4.0 (0.9-21) x 10(6) CD34+ cells/kg. Of 20 patients, 17 (85%) reached the defined target of >/=2.0 x 10(6) CD34+ cells/kg after 1-3 leukaphereses. We conclude that HiDAC+AMSA+G-CSF - in contrast to mini-ICE+G-CSF - is an efficient regimen for mobilising PBSC in patients with AML CR1.

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

In this prospective randomized multicenter trial 93 patients, median age 72 years, with RAEB-t (n=25) and myelodysplastic syndrome (MDS)-AML (n=68) were allocated to a standard induction chemotherapy regimen (TAD 2+7) with or without addition of granulocyte-macrophage-CSF (GM-CSF). The overall complete remission (CR) rate was 43% with no difference between the arms. Median survival times for all patients, CR patients, and non-CR patients were 280, 550, and 100 days, respectively, with no difference between the arms. Response rates were significantly better in patients with serum lactate dehydrogenase (S-LDH) levels </=9.5 microkat/l, bone marrow cellularity </=70%, and WBC counts <4.0 x 10(9)/l, but S-LDH was the only variable independently associated with response by logistic regression analysis. Cox's regression analysis identified four significant prognostic factors for survival: bone marrow cellularity, S-LDH, cytogenetic risk group (International Prognostic Scoring System), and age. Only bone marrow cellularity (P=0.01) and S-LDH (P=0.0003) retained statistical significance in the log-rank test. Severe adverse events were significantly more common in the GM-TAD arm (P=0.01). Thus, addition of GM-CSF to chemotherapy showed no clinical benefit in terms of response but carried an increased risk for side effects. We present a clinically useful tool to predict response to chemotherapy and survival in elderly patients with transforming MDS, favoring patients with features of less proliferative disease.

Cognitive performance in very old diabetic persons: the impact of semantic structure, preclinical dementia, and impending death

The authors examined the associations of diabetes mellitus with cognitive performance in a population-based sample of nondemented and nondepressed very old persons. Diabetic participants (n = 31) were compared with nondiabetic controls (n = 307), adjusting for age, educational level, and related vascular diseases and signs. Results showed that diabetic persons performed significantly worse on tests of verbal fluency and episodic memory but that the effects on both types of abilities were less pronounced in tasks involving higher degrees of semantic structure. Follow-up analyses further revealed that preclinical dementia and impending death accounted for much of the observed associations. The results suggest that cognitive deficits among very old diabetics are most likely detected by tasks that draw less on semantic structures and that the most robust effects may be found in letter fluency performance.

Prognostic significance of risk group stratification in elderly patients with acute myeloid leukaemia

Prognostic factors were studied in a series of 211 acute myeloid leukaemia (AML) patients over 60 years of age, treated at a single centre. The patients were allocated into three risk groups based on cytogenetics, occurrence of antecedent haematological disorder and leucocyte count. Only 3% had low-risk features, 39% had intermediate- and 58% had adverse-risk features. Complete remission (CR) was achieved in 43% of all patients. In multivariate analyses, the number of cycles needed to achieve CR and the risk group were significantly associated with the duration of CR. Median survival time for the entire cohort of patients was only 107 d. Advanced age, low induction treatment intensity, treatment during earlier years and adverse-risk group were associated with shorter overall survival times. Risk group classification may help selection of elderly patients with a good chance of benefiting from intensive treatment to actually receive such treatment, while sparing others with a low probability of survival benefit from toxic treatment. Low intensity induction treatment reduces the chance of obtaining complete remission, produces inferior survival times and should consequently be avoided when the aim is to obtain complete remission. In elderly AML patients, introducing age and re-evaluation of intermediate and good prognosis patients regarding response to induction treatment may improve the risk group classification.

Glycoconjugate abnormalities in patients with congenital dyserythropoietic anaemia type I, II and III

Congenital dyserythropoietic anaemia type II (CDA II) is well known for glycosylation abnormalities affecting erythrocyte membrane glycoconjugates that encompass hypoglycosylation of band 3 glycoprotein and accumulation of glycosphingolipids: lactotriaosylceramides, neolactotriaosylceramide and polyglycosylceramides. These abnormalities were not observed in erythrocytes from patients with CDA of either type I or III. Recently, however, we have described a CDA type I patient in Poland with identical, though less pronounced, glycoconjugate abnormalities to those observed in patients with CDA type II. The abnormalities included partial unglycosylation of O-linked glycosylation sites in glycophorin A. These abnormalities are now reported in three Bedouin patients from Israel with CDA type I. In addition, the erythrocyte membranes of these patients exhibited highly increased globotetraosylceramide content. Glycoconjugate abnormalities were also present in erythrocyte membranes from three patients from Northern Sweden with CDA type III but they almost exclusively affected glycosphingolipids. In erythrocytes of all patients examined including one with CDA type II, polyglycosylceramides were significantly hypoglycosylated although, on a molar basis, their contents in erythrocyte membranes were increased. Thus, glycoconjugate abnormalities of varying intensity occur in erythrocyte membranes from all patients with CDA that were investigated.

Geriatric-based versus general wards for older acute medical patients: a randomized comparison of outcomes and use of resources

BACKGROUND

The effects of residence in an acute geriatrics-based ward (AGW) with emphasis on early rehabilitation and discharge planning for older patients with acute medical illnesses were assessed. Outcome and use of resources were compared with those of patients treated in general medical wards (MWs). A per-protocol rather than intention-to-treat analysis was performed.

METHODS

A randomized trial with 3-months follow-up. A total of 190 patients aged 70 years and older were randomized to an acute geriatrics-based ward, and 223 patients were randomized to general medical wards.

RESULTS

The two groups were comparable at inclusion. However, after care in the AGW, 71% of patients could be discharged directly home compared with 64% of those treated in MWs (relative risk 1.17; 95% CI, 0.93-1.49). The length of stay was shorter in the AGW (mean 5.9 vs 7.3 days; P = .002). The proportion of patients in geriatric or other hospital wards or in nursing homes did not differ, but the proportion of AGW patients in sheltered living tended to be lower (P = .085). At the follow-up, case fatality, ADL function, psychological well-being, need for daily personal assistance, drug consumption, need for readmission to hospital, and total health care costs after discharge did not differ between the two groups. Poor global outcome was observed in 37% of AGW and 34% of MW patients.

CONCLUSIONS

A geriatric approach with greater emphasis on early rehabilitation and discharge planning in the AGW shortened the length of hospital stay and may have reduced the need for long-term institutional living. This occurred despite patients in an acute geriatric ward not having better medical or functional outcome than older acute patients treated in general medical wards.

The relationship between signs of cardiovascular deficiency and cognitive performance in old age: a population-based study

The influence of cardiovascular signs (CVS) on cognitive performance was examined in 227 older adults not suffering from dementia between 75 and 96 years of age who were sampled from the community. Participants received a comprehensive physical examination that included specific evaluation of current CVS, including dyspnea, cardiac murmur, and edema in lower limbs. They were administered tests of digit span, episodic recall and recognition, verbal fluency, and visuospatial skill. CVS were found to predict performance on tests of episodic memory and visuospatial skill, after the effects of age, education, gender, relevant drug use, and mood symptoms were controlled for. Although CVS accounted for relatively little general performance variation, the findings are relevant to the understanding of normal variation in late-life cognitive performance. Finally, CVS increased with age and accounted for a sizable proportion of the age-related cognitive variation.

Congenital dyserythropoietic anemia type III

BACKGROUND AND OBJECTIVES

Congenital dyserythropoietic anemia type III (CDA-III) is a group of very rare disorders characterized by similar bone marrow morphology. The clinical picture is characterized by hemolytic anemia and dramatic bone marrow changes dominated by active erythropoiesis with big multinucleated erythroblasts. The aim of this review is to describe the clinical manifestations, laboratory findings, and management CDA-III.

EVIDENCE AND INFORMATION SOURCES

The present review critically examines relevant articles and abstracts published in journals covered by the Science Citation Index and Medline. The authors have performed several studies on CDA-III.

STATE OF ART AND PERSPECTIVES

The clinical and laboratory manifestations of CDA-III indicate that the gene responsible for it, which has been mapped to chromosome 15q22, is expressed not only in erythroblasts during mitosis but also in B-cells, and in cells of the retina. Preliminary results indicate genetic and phenotypic similarities between a Swedish and an American family, both with an autosomally dominant inherited form of CDA-III. It is possible that the genetic lesion is identical in these families, but the different phenotypes and modes of inheritance reported among some other cases of CDA-III are probably the results of other genetic lesions. At present, the function of the gene responsible for the Swedish (V sterbotten) variant of CDA-III (CDAN3) is unknown and it is an important goal to characterize and clone this gene in order to study its function.

Age-related cognitive deficits mediated by changes in the striatal dopamine system

OBJECTIVE

The study examined the influence of losses in dopaminergic function on age-related cognitive deficits.

METHOD

Eleven healthy subjects (21-68 years of age) completed a set of cognitive tasks used to assess perceptual speed and episodic memory. D(2) receptor binding was measured in the caudate and the putamen by using positron emission tomography.

RESULTS

A gradual age-related deterioration was found for all cognitive tasks and for D(2) binding in both striatal structures. Statistical control of D(2) binding eliminated the age-related cognitive variation, whereas residual effects of D(2) binding were seen after the analysis controlled for age.

CONCLUSIONS

D(2) receptor binding is a more important factor than chronological age in accounting for variation in cognitive performance across the adult lifespan. Changes in dopaminergic neurotransmission play an important role in aging-related cognitive decline.