Routine double-ovarian-stimulation (DuoStim) in poor responders lacks rationale, evidence, and follow-up

Double ovarian stimulation (DuoStim), initially only suggested for fertility preservation in cancer patients, is now increasingly also used in routine clinical IVF, especially in poor responders. The claimed rational for this is the alleged existence of multiple follicular waves in a single intermenstrual interval, allowing for retrieval of more oocytes in a single IVF cycle. This commentary argues that this expansion of purpose lacks rationale, evidence, and follow-up. Consequently, we suggest that, unless valid clinical indications have been established, DuoStim be only subject of controlled clinical trials with appropriate experimental consents.

Why double ovarian stimulation in an in vitro fertilization cycle is potentially unsafe

The occurrence of two antral follicle recruitment waves in a single inter-ovulatory interval has been detected in ovaries of normal women. This data supports the claim that a double ovarian stimulation in the same cycle may benefit poor responder patients with an increased recovery of mature oocytes and good quality embryos per single cycle. The double stimulation protocol was the object of several published studies in which, surprisingly, the mechanism and the safety of the double stimulation in the same cycle were poorly addressed. We propose that in the double stimulation protocol, the first stimulation impacts more committed oocytes progenitors ready to differentiate into mature oocytes. Conversely, the protracted exposure of developmentally earlier less-committed ovarian stem cells to FSH, which occurs in the double stimulation protocol, impacts the less differentiated stem cells which take longer to differentiate into oocytes. The proposed mechanism has broad implications for the safety of the double stimulation strategy.

The safety of VASApos presumptive adult ovarian stem cells

Isolation and characterization of presumptive human adult ovarian stem cells (OSC) has broken the long standing dogma of the absence of postnatal neo-oogenesis. Human adult OSC have been immunosorted by antibodies reacting against the RNA helicase VASA and have been reported to engraft into appropriate stem cell niches to promote neo-oogenesis. Analysis of published research, however, questions some of the findings on isolation, characterization, in-vitro self-renewal and clinical safety of the presumptive human adult OSC. In the present study, human VASA^pos embryo-fetal primordial germ cells and presumptive adult OSC are shown to share several pluripotency and early germ cell markers not ascertained in the initial characterization of adult OSC. A new hypothesis is made that the restoration of fertility claimed to result from presumptive human adult OSC may be attributed instead to VASA^pos embryo-fetal primordial germ cell remnants in the adult ovary, or alternatively to earlier VASA^neg germ cells generated by in-vitro de-differentiation of the presumptive OSC. The suggested hypotheses have extensive implications for the practice and safety of adult OSC in the development of new treatments aimed at rescuing the ovarian reserve.

The unknown human trophectoderm: implication for biopsy at the blastocyst stage

Trophectoderm biopsy is increasingly performed for pre-implantation genetic testing of aneuploidies and considered a safe procedure on short-term clinical outcome, without strong assessment of long-term consequences. Poor biological information on human trophectoderm is available due to ethical restrictions. Therefore, most studies have been conducted in vitro (choriocarcinoma cell lines, embryonic and pluripotent stem cells) and on murine models that nevertheless poorly reflect the human counterpart. Polarization, compaction, and blastomere differentiation (e.g., the basis to ascertain trophectoderm origin) are poorly known in humans. In addition, the trophectoderm function is poorly known from a biological point of view, although a panoply of questionable and controversial microarray studies suggest that important genes overexpressed in trophectoderm are involved in pluripotency, metabolism, cell cycle, endocrine function, and implantation. The intercellular communication system between the trophectoderm cells and the inner cell mass, modulated by cell junctions and filopodia in the murine model, is obscure in humans. For the purpose of this paper, data mainly on primary cells from human and murine embryos has been reviewed. This review suggests that the trophectoderm origin and functions have been insufficiently ascertained in humans so far. Therefore, trophectoderm biopsy should be considered an experimental procedure to be undertaken only under approved rigorous experimental protocols in academic contexts.

Bone Marrow Biopsy for the Staging of Non-Hodgkin's Lymphoma: Bilateral or Unilateral Trephine Biopsy?

Aim

The occurrence of unilateral involvement in bilateral bone marrow trephine biopsies in non-Hodgkin's lymphomas (NHL) at disease onset (10-20% of cases) has been reported since the early 70s. Therefore, although these studies were based on small series, the use of bilateral bone marrow biopsies has become the rule. However, the clinical value of this procedure has never been clearly established. The aim of the present study was to ascertain the true value of bilateral bone marrow biopsy in the staging of NHL.

Study Design

We examined 368 cases of NHL (A-H according to the Working Formulation) (WF), without leukemic involvement of the peripheral blood, in order to evaluate: 1) the incidence of unilateral bone marrow involvement; 2) the percentage of patients who, as a result of unilateral bone marrow involvement, changed from stages I-II to stage IV; 3) assessment of response to therapy for patients with both bilateral or unilateral bone marrow involvement.

Results

In the A-C NHL groups of WF there was a unilateral bone marrow involvement of 8.8%. Overall, bone marrow involvement induced a change from clinical stages I-II to stage IV in 5.6% of cases, a figure which would correspond to a false negative rate of 2.8%, if unilateral bone marrow biopsy was performed. In the D-F and G, H groups of WF, unilateral involvement was 10.1% and 8.5% respectively; the change in stage from I-II to IV by unilateral bone marrow involvement respectively amounted to 1.4% and 2.8%, which correspond to respective false negative rates of 0.7% and 1.4%.

Conclusions

On the basis of these results and of the present therapeutic strategies, we propose: bilateral bone marrow biopsy for clinical stages I-II of all NHL; no bone marrow biopsy at disease onset for clinical stages III and IV of A to H histologic subtypes of the WF; unilateral bone marrow biopsy (A-C subtypes of the WF) or bilateral (D-H of the WF), after the regression of extramedullary localizations.

Inappropriate Doses of Chemotherapy in Italian Breast Cancer Patients Enrolled in Clinical Trials

Aims and background

The dose of delivered chemotherapy is important to evaluate the appropriateness of the anticancer treatment. This aspect has been scarcely studied in Italy. About 7 years ago, the Italian Group for Antiemetic Research (IGAR) published a large controlled study on the effectiveness of different antiemetic prophylaxis in patients submitted to moderately emetogenic chemotherapy, where the prescribed chemotherapy was recorded. The aim of our study was to evaluate the incidence of undertreatment and to detect clinical and nonclinical factors able to explain its variability.

Methods

An observational study on the IGAR databank was performed to evaluate the incidence of undertreatment in the prescription in conditions of clinical trial, where the doses belonged to the eligibility criteria, and to analyze the importance of clinical and nonclinical factors using multifactorial logistic models.

Results

317 patients receiving cyclophosphamide, methotrexate, and fluorouracil (CMF) and 224 anthracycline-based chemotherapy were considered. In the CMF-treated patients, 22.4% received full doses, whereas in 53.6% all three drugs of the schedule were down-dosed. In the anthracycline-treated group, 38.6% and 3.4% of patients submitted to chemotherapy containing epirubicin and doxorubicin, respectively, were undertreated. Logistic models showed that undertreatment in CMF-treated patients depended significantly on the geographic area and setting of chemotherapy administration. Although not significant, differences between age class and Karnofsky performance status were also detected. In the epirubicin-treated group, all these factors were significant.

Conclusions

The undertreatment of cancer patients is a relevant problem, because it could give, in daily clinical practice, worse results than those reported in clinical studies. Considering the setting of a clinical trial where our study was carried out, the incidence of undertreatment is surprisingly high. We do not know whether today, about 8 years after the IGAR study was carried out, the inappropriate dose of chemotherapy is still as frequent as we reported, but surely the topic deserves more attention.

Aprepitant versus metoclopramide, both combined with dexamethasone, for the prevention of cisplatin-induced delayed emesis: a randomized, double-blind study

BACKGROUND

A combination of aprepitant, a 5-HT3 receptor antagonist (r.a.), and dexamethasone is recommended for the prophylaxis of cisplatin-induced nausea and vomiting in the acute phase, and aprepitant + dexamethasone (A + D) in the delayed phase. The aim of this study was to verify if A + D is superior to metoclopramide plus dexamethasone (M + D) in preventing delayed emesis in cancer patients receiving the same prophylaxis for acute emesis.

PATIENTS AND METHODS

A randomized double-blind study comparing A + D versus M + D was completed in previously untreated cancer patients. Before chemotherapy, all patients were treated with intravenous palonosetron 0.25 mg and dexamethasone 12 mg, and oral aprepitant 125 mg. On day 2-4, patients randomly received oral dexamethasone 8 mg plus aprepitant 80 mg once daily (days 2-3) or metoclopramide 20 mg four times daily plus dexamethasone 8 mg bid. Primary endpoint was rate of complete response (no vomiting, no rescue treatment) in day 2-5 after chemotherapy.

RESULTS

Due to difficulty in the accrual of patients, 303 of the 480 planned patients were enrolled, 284 were fully evaluable, 147 receiving A + D, 137 M + D. Day 1 results were similar in both arms. On day 2-5, complete response rate was not significantly different (80.3% with A + D versus 82.5% with M + D, P < 0.38, respectively), and all secondary endpoints were also similar (complete protection, total control, no vomiting, no nausea, and score of Functional Living Index-Emesis; P < 0.24). Adverse events incidence was not significantly different between the two treatments.

CONCLUSIONS

In cancer patients submitted to cisplatin-based chemotherapy, receiving the same antiemetic prophylaxis for acute emesis, A + D is not superior to M + D in preventing delayed emesis, and both treatments present similar toxicity.

CLINICALTRIALSGOV NUMBER

NCT00869310.

Comparison of intrafollicular sperm injection and intrauterine insemination in the treatment of subfertility

PURPOSE

To compare the efficacy of intrafollicular sperm injection (IFI) versus intrauterine insemination (IUI) in the treatment of subfertility.

METHODS

38 couples suffering primary or secondary subfertility contributed a total of 47 IUI or IFI cycles, 26 by IUI and 21 by IFI. Folliculogenesis, ovulation triggering, and IUI or IFI were performed. Motile spermatozoa were inseminated into the uterine cavity for IUI or injected into pre-ovulatory follicles for IFI. The rate of biochemical and clinical pregnancy was assessed.

RESULTS

The rate of biochemical pregnancy/cycle for IUI was 11 % as compared to 38 % for IFI (p = 0.04). The rate of clinical pregnancy/cycle for IUI was 11 % as compared to 29 % for IFI (p = 0.26). The rate of twin pregnancy and miscarriage was low and no high order multiple gestation was observed. The rate of ectopic tubal pregnancy/cycle for IUI was 0 % as compared to 9 % for IFI (p = 0.19); no ovarian pregnancy was observed. When the analysis was confined to IFI cycles in which 2.68-6.65 million motile spermatozoa were injected/follicle (n = 10), a rate of 60 % clinical pregnancy/cycle was observed, of which 2 were ectopic.

CONCLUSION

Under the conditions described herein, IFI was more effective than IUI at achieving pregnancy.

Ultrasound study of the myoendometrial border

Abnormal thickening of the Endometrial Subendometrial Myometrium Unit (ESEMy Unit, including basal endometrium and inner myometrium) has been detected on imaging and referred to as "diffuse adenomyosis" in infertile patients with proven endometriosis. However, no robust relationship exists between enlargement of the ESEMy Unit and adenomyosis proven on hysterectomy specimen examination; moreover, if any correlation exists, it lacks histological validation in women wishing to preserve fertility. While adenomyosis effects on fertility, if any, remain elusive, thickening of the ESEMy Unit have been consistently linked to fertility impairment in both experimental and clinical models. The hypothesis tested herein is that a novel condition exists, called "ESEMy Unit disruption disease"; it is epidemiologically different from adenomyosis, diagnosable on imaging and bears a clear impact on human fertility through various mechanisms. A new wave of good quality studies may be elicited by a clear distinction between adenomyosis and the "ESEMy Unit disruption disease".

Negligible serum anti-müllerian hormone: pregnancy and birth after a 1-month course of an oral contraceptive, ovarian hyperstimulation, and intracytoplasmic sperm injection

OBJECTIVE

To describe a patient with isolated negligible (<0.5 ng/mL or <3.6 pmol/L) anti-müllerian hormone (AMH) levels who underwent intracytoplasmic sperm injection (ICSI) for severe oligoasthenoteratozoospermia, displayed ovarian hyperstimulation after a 1-month course of an oral contraceptive (OC), had a singleton pregnancy and delivered a healthy boy.

DESIGN

Case report.

SETTING

Reproductive center at a private hospital.

PATIENT(S)

A 34-year-old woman with isolated negligible (<0.5 ng/mL or <3.6 pmol/L) AMH level and poor response to controlled ovarian hyperstimulation (COH) and her 38-year-old partner with severe oligoasthenoteratozoospermia.

INTERVENTION(S)

A 1-month course of an OC, modified minimal stimulation cycle with recombinant FSH, antagonist (cetrorelix) administration to inhibit LH surge, triggered ovulation using 10,000 U of hCG and ICSI.

MAIN OUTCOME MEASURE(S)

Level of AMH, pregnancy, and birth.

RESULT(S)

Three high quality embryos were obtained and transferred 48 hours after ICSI. Transvaginal ultrasound at 8 weeks' gestation showed a vital singleton pregnancy. The pregnancy continued uncomplicated. The patient gave birth to a healthy boy, weighing 3,280 g, by caesarean section at 39 weeks' gestation.

CONCLUSION(S)

Ovarian hyperstimulation, pregnancy, and birth may occur after a short course of an OC and ICSI in poor responder, normogonadotropic, regularly menstruating young women with isolated negligible AMH.

Brain network analysis from high-resolution EEG recordings by the application of theoretical graph indexes

The extraction of the salient characteristics from brain connectivity patterns is an open challenging topic since often the estimated cerebral networks have a relative large size and complex structure. Since a graph is a mathematical representation of a network, which is essentially reduced to nodes and connections between them, the use of a theoretical graph approach would extract significant information from the functional brain networks estimated through different neuroimaging techniques. The present work intends to support the development of the "brain network analysis:" a mathematical tool consisting in a body of indexes based on the graph theory able to improve the comprehension of the complex interactions within the brain. In the present work, we applied for demonstrative purpose some graph indexes to the time-varying networks estimated from a set of high-resolution EEG data in a group of healthy subjects during the performance of a motor task. The comparison with a random benchmark allowed extracting the significant properties of the estimated networks in the representative Alpha (7-12 Hz) band. Altogether, our findings aim at proving how the brain network analysis could reveal important information about the time-frequency dynamics of the functional cortical networks.

Cortical activity and connectivity of human brain during the prisoner's dilemma: an EEG hyperscanning study

A major limitation of the approaches used in most of the studies performed so far for the characterization of the brain responses during social interaction is that only one of the participating brains is measured each time. The "interaction" between cooperating, competing or communicating brains is thus not measured directly, but inferred by independent observations aggregated by cognitive models and assumptions that link behavior and neural activation. In this paper, we use the simultaneous neuroelectric recording of several subjects engaged in cooperative games (EEG hyperscanning). This EEG hyperscanning allow us to observe and model directly the neural signature of human interactions in order to understand the cerebral processes generating and generated by social cooperation or competition. We used a paradigm called Prisoner's dilemma derived from the game theory. Results collected in a population of 22 subjects suggested that the most consistently activated structure in social interaction paradigms is the medial prefrontal cortex, which is found to be active in all the conflict situations analyzed. The role of the anterior cingulated cortex (ACC) assumes a main character being a discriminant factor for the "defect" attitude of the entire population examined. This observation is compatible with the role that the Theory of Mind assigns to the ACC.

High resolution EEG hyperscanning during a card game

In order to study the concurrent activity in subjects interacting in cooperation or competition activities, the issue of the simultaneous recording of their brain activity became mandatory. The simultaneous recording of neuroelectric activity of the brain is called "EEG hyperscanning". We would like present results obtained by EEG hyperscannings performed on a group of subjects engaged in a card game. The EEG hyperscannings have been performed with the simultaneous use of high resolution EEG devices on groups of four subjects while they were playing a card game. We estimated the concurrent activity in multiple brains of the group and we depicted the causal connections between regions of different brains. Results obtained in a study of several groups recorded by the EEG hyperscanning reveal larger activity in prefrontal and anterior cingulated cortex in different frequency bands for the player that start the game when compared to other players. EEG hyperscannings will open a different area for the study of neuroscience, in which the activity of multiple brains during social cooperation could be investigated.

Tracking the time-varying cortical connectivity patterns by adaptive multivariate estimators

The directed transfer function (DTF) and the partial directed coherence (PDC) are frequency-domain estimators that are able to describe interactions between cortical areas in terms of the concept of Granger causality. However, the classical estimation of these methods is based on the multivariate autoregressive modelling (MVAR) of time series, which requires the stationarity of the signals. In this way, transient pathways of information transfer remains hidden. The objective of this study is to test a time-varying multivariate method for the estimation of rapidly changing connectivity relationships between cortical areas of the human brain, based on DTF/PDC and on the use of adaptive MVAR modelling (AMVAR) and to apply it to a set of real high resolution EEG data. This approach will allow the observation of rapidly changing influences between the cortical areas during the execution of a task. The simulation results indicated that time-varying DTF and PDC are able to estimate correctly the imposed connectivity patterns under reasonable operative conditions of signal-to-noise ratio (SNR) ad number of trials. An SNR of five and a number of trials of at least 20 provide a good accuracy in the estimation. After testing the method by the simulation study, we provide an application to the cortical estimations obtained from high resolution EEG data recorded from a group of healthy subject during a combined foot-lips movement and present the time-varying connectivity patterns resulting from the application of both DTF and PDC. Two different cortical networks were detected with the proposed methods, one constant across the task and the other evolving during the preparation of the joint movement.

Features extraction from time-varying cortical networks adopting a theoretical graph approach

In this work, a novel approach is proposed in order to capture relevant features related to the structure and organization of the functional brain networks estimated in the time-frequency domain. To achieve this, we used a cascade of computational tools able to estimate first the electrical activity of the cortical surface by using high resolution EEG techniques. Then, on the cortical signals from different regions of interests we estimated the time-varying functional connectivity patterns by means of the adaptive Partial Directed Coherence. Such time-varying connectivity estimation returns a series of causality patterns evolving during the examined task which can be summarized and interpreted with the aid of mathematical indexes based on the graph theory. The combination of all these methods is demonstrated on a set of high resolution EEG data recorded from a healthy subject performing a simple foot movement.

Mesenchymal stem cell: use and perspectives

Studies on hematopoiesis have focused on the function and composition of human bone marrow stroma. Stroma function gives hematopoietic stem cells the microenvironment appropriate for self-renewal and/or prompt differentiation into hematopoietic progenitor cells, then into terminal specialized cells. Human bone marrow stroma has been dissected into hematopoietic and nonhematopoietic components. The former includes hematopoietic-derived cells, mainly macrophages, while the latter, still poorly characterized, is composed mainly of endothelial and mesenchymal stem cells and their derivatives (adipocytes, chondrocytes, cells of the osteogenic lineage). Isolation of bone marrow mesenchymal stem cells has made available a population of adherent cells, belonging to the non-hematopoietic stroma, which are morphologically and phenotypically homogeneous. This review will focus on: (i) definition of bone marrow stroma and mesenchymal stem cells; (ii) methods of mesenchymal stem cell isolation, morphological and phenotypic characterization; (iii) mesenchymal stem cell functional and differentiation properties and (iv) therapeutic applications of mesenchymal stem cells.

CD34+ cells from first-trimester fetal blood are enriched in primitive hemopoietic progenitors

OBJECTIVE

The purpose of this study was to investigate whether purified CD34(+) cells from first-trimester fetal blood are a source of primitive and committed hemopoietic progenitors.

STUDY DESIGN

CD34(+) cells from first-trimester fetal blood and term cord blood were assayed for committed hemopoietic progenitor cells, high proliferative potential colony-forming cells, and long-term culture-initiating cells.

RESULTS

First-trimester CD34(+) cells that were compared with cells at term generated fewer hemopoietic progenitor cells and fewer high proliferative potential colony-forming cells with lower recloning efficiency(P <.001). First-trimester CD34(+) cells tended to contain more long-term culture-initiating cells, both in bulk cultures and by limiting dilution analysis. The ratio between committed and primitive progenitors was 3 in the first-trimester and 20 in the term cord blood, respectively.

CONCLUSION

First-trimester fetal blood is enriched in primitive (compared with committed) hemopoietic progenitors and may be an advantageous source of stem cells for prenatal therapy.

[Use of the TUT (Tension-free Vaginal Tape) in the treatment of female urinary stress incontinence. Preliminary results]

BACKGROUND

The Tension-free Vaginal Tape (TVT) represents the most recent technique for the treatment of genuine stress urinary incontinence (GSUI). The various number of surgical procedures proposed for the treatment of GSI very often do not lead to a complete remission of this pathology. The data from the literature show how TVT is a effective procedure for the treatment of female urinary incontinence.

METHODS

Twenty-nine women with diagnosis of urinary incontinence underwent application of polypropilene band (TVT: tension-free vaginal tape) underneath the uretra, in order to treat this disorder. The procedure has been carried out in peripheral anesthesia.

RESULTS

A complete remission of the urinary incontinence was obtained in 24 patients. In the remaining cases there was an improvement of the symptoms in two patients, whereas in two patients remained a secondary detrusor instability. In one case the external iliac vein was perforated thus requiring a surgical repair.

CONCLUSION

The short surgical time, the feasibility of the procedure and the following short hospitalization made this technique well accepted either by the surgeons ang the patients. Moreover the possibility to carry out the procedure in peripheral anesthesia allows to have the collaboration of the patient. However this technique is not free of risks, how the serious complication we had can demonstrate.

Enforced TAL-1 expression stimulates primitive, erythroid and megakaryocytic progenitors but blocks the granulopoietic differentiation program

In human adult hematopoiesis, the TAL-1 gene is up- and down-modulated in erythropoiesis and granulopoiesis, respectively [G. L. Condorelli et al., Blood, 86: 164-175, 19951. Here, it is shown that, in a hematopoietic progenitor cell (HPC) unilineage differentiation culture, tal-1 is induced and then expressed, in a sustained manner, in the megakaryopoietic lineage, whereas it is barely or not detected in the monocytopoietic series. We have investigated the role of enforced tal-1 expression by retroviral transfer into HPCs [erythroid burst-forming units and megakaryocytic and granulomonocytic colony-forming units (CFUs)], primitive HPCs (high proliferative potential colony-forming cells), and putative hematopoietic stem cells (HSCs), assayed as long-term culture initiating cells. TAL-1 overexpression induces an increase of erythroid burst-forming unit colony number and size and megakaryocytic CFU colony number and an inhibition of granulomonocytic CFU and granulocytic CFU (CFU-G) but not monocytic CFU colony number; conversely, TAL-1 mutants with defective heterodimerizing or DNA-binding domains do not exert these effects at a significant level. Although it does not affect long-term culture initiating cells, exogenous TAL-1 causes a significant proliferative stimulus on primary and secondary high proliferative potential colony-forming cells. In conclusion, exogenous tal-1 exerts differential and stage- and lineage-specific effects on the HPC/HSC differentiation/proliferation gene programs. Thus, it induces a stimulatory effect at the level of erythroid and megakaryocytic HPCs, while exerting a selective proliferative action on downstream erythropoiesis. Furthermore, it induces differential effects on the myeloid series: the partial blockade of CFU-G differentiation is possibly linked to the sharp down-modulation of endogenous TAL-1 expression at the level of the CFU-G-to-granulopoietic precursor differentiation step; in contrast, no significant effect is observed on monocytic CFU colony formation. Finally, the stimulatory effect on primitive HPCs but not putative stem cells suggests subtle differences in the effects exerted by tal-1 overexpression on primitive HPC/HSC subsets in adult life.

Ectopic TAL-1/SCL expression in phenotypically normal or leukemic myeloid precursors: proliferative and antiapoptotic effects coupled with a differentiation blockade

The TAL-1 gene specifies a basic helix-loop-helix domain (bHLH) transcription factor, which heterodimerizes with E2A gene family proteins. tal-1 protein is abnormally expressed in the majority of T-cell acute lymphoblastic leukemias (T-ALLs). tal-1 is expressed and plays a significant role in normal erythropoietic differentiation and maturation, while its expression in early myeloid differentiation is abruptly shut off at the level of late progenitors/early differentiated precursors (G. L. Condorelli, L. Vitelli, M. Valtieri, I. Marta, E. Montesoro, V. Lulli, R. Baer, and C. Peschle, Blood 86:164-175, 1995). We show that in late myeloid progenitors (the phenotypically normal murine 32D cell line) and early leukemic precursors (the human HL-60 promyelocytic leukemia cell line) ectopic tal-1 expression induces (i) a proliferative effect under suboptimal culture conditions (i.e., low growth factor and serum concentrations respectively), via an antiapoptotic effect in 32D cells or increased DNA synthesis in HL-60 cells, and (ii) a total or marked inhibitory effect on differentiation, respectively, on granulocyte colony-stimulating factor-induced granulopoiesis in 32D cells or retinoic acid- and vitamin D3-induced granulo- and monocytopoiesis in HL-60 cells. Furthermore, experiments with 32D temperature-sensitive p53 cells indicate that aberrant tal-1 expression at the permissive temperature does not exert a proliferative effect but causes p53-mediated apoptosis, i.e., the tal-1 proliferative effect depends on the integrity of the cell cycle checkpoints of the host cell, as observed for c-myc and other oncogenes. tal-1 mutant experiments indicate that ectopic tal-1 effects are mediated by both the DNA-binding and the heterodimerization domains, while the N-terminally truncated tal-1 variant (M3) expressed in T-ALL malignant cells mimics the effects of the wild-type protein. Altogether, our results (i) indicate proliferative and antidifferentiative effects of ectopic tal-1 expression, (ii) shed light on the underlying mechanisms (i.e., requirement for the integrity of the tal-1 bHLH domain and cell cycle checkpoints in the host cell, particularly p53), and (iii) provide new experimental models to further investigate these mechanisms.

Human fetal liver cells induce colonies in spleen of lethally irradiated mice

Murine hematopoietic tissues contain cells which, upon injection into lethally irradiated mice, produce nodules on the surface of their spleen (colony-forming unit--spleen; CFU-S). The exact hierarchical level of the hematopoietic progenitors which give rise to CFU-S is not fully established; however, cell populations highly enriched for repopulating stem cells appear to contain a high percentage of CFU-S. The experiments reported here involved the injection of human fetal liver cells into mice, under conditions similar to those of the CFU-S test. These data demonstrate that human fetal liver cells are able to induce spleen colonies (tentatively called human CFU-S) when injected into lethally irradiated mice. The number of CFU-S was increased by prior purification of human fetal liver cells. When mice were injected with human fetal liver cells inactivated by irradiation, no human CFU-S were observed. Positive staining of cells found in spleen colonies, using monoclonal antibodies specific for various human determinants, indicated the human origin of part of them. The presence of human cells within the colonies was further confirmed by in situ hybridization using a probe specific for human DNA. A mean of 30-40% of analyzed colonies was thus shown to contain some patches of human cells. These data confirm that human hematopoietic cells are able to seed, proliferate, and differentiate in a murine microenvironment.

Acute hepatic toxicity during cyclic chemotherapy in non Hodgkin's lymphoma

BACKGROUND AND OBJECTIVE

Hepatic toxicity directly related to the drugs administered in cyclic chemotherapy (CT), although sometimes serious, does not limit the treatment of non-Hodgkin's lymphoma (NHL). Nevertheless, reports of reactivation of viral hepatitis in NHL patients with B virus (HBV) infection are becoming more frequent. The recent observation of two cases of severe liver toxicity directly correlated to CT and a case of fatal hepatic failure due to HBV replication prompted us to evaluate the hepatic toxicity of CT in 98 consecutive B-cell NHL patients treated with relatively homogeneous cyclic CT.

METHODS

Acute hepatic toxicity was retrospectively evaluated in 98 consecutive B-cell NHL patients who received induction CT. HBV and HCV markers were checked at presentation. All patients were tested for ALT and bilirubin before every CT course, while tests for HBV-DNA and/or for HCV-RNA were performed with PCR only when hepatitis occurred.

RESULTS

At presentation 22 patients (22.4%) were positive for HBsAg, and 11 (15.9%) were positive for anti-HCV. Acute hepatitis developed in 12 (12.2%) NHL patients: 8 (out of 22) in HBsAg-positive and anti-HCV-negative patients, 3 (out of 76) in HBsAg-negative patients, and 1 (out of 11) in anti-HCV-positive patients. Hepatitis was attributed to reactivation of chronic B hepatitis in 3 patients and to drug toxicity in 3 others; hepatitis was undefined in 6 cases.

INTERPRETATION AND CONCLUSIONS

Drug-related liver toxicity is not a rare occurrence in NHL patients. Reactivation of HBV replication is responsible for a relevant number of the hepatitis cases observed. We did not detect acute hepatitis due to the reactivation of HCV replication (in chronic C hepatitis carriers).

Dual action of retinoic acid on human embryonic/fetal hematopoiesis: blockade of primitive progenitor proliferation and shift from multipotent/erythroid/monocytic to granulocytic differentiation program

In preliminary studies, we have analyzed the hematopoietic growth factor (HGF) requirement of hematopoietic progenitor cells (HPCs) purified from embryonic-fetal liver (FL) and grown in fetal calf serum-supplemented (FCS+) clonogenic culture. The key role of erythropoietin (Epo) for colony formation by early erythroid progenitors (burst-forming units-erythroid [BFU-E]) has been confirmed. Furthermore, in the absence of exogenous HGFs, FL monocytic progenitors (colony-forming unit monocyte [CFU-M]) generate large colonies exclusively composed of monocytes-macrophages; these colonies are absent in FCS- clonogenic culture. On this basis, we have investigated the role of all-trans retinoic acid (ATRA) and its isomer 9-cis RA in FL hematopoiesis. Both compounds modulate the growth of purified FL HPCs, which show a dose-dependent shift from mixed/erythroid/ monocytic to granulocytic colony formation. Studies on unicellular and paired daughter cell culture unequivocally indicate that the shift is mediated by modulation of the HPC differentiation program to the granulopoietic pathway (rather than RA-induced down-modulation of multipotent/ erythroid/monocytic HPC growth coupled with recruitment of granulocytic HPCs). ATRA and 9-cis RA also exert their effect on the proliferation of primitive HPCs (high-proliferative potential colony-forming cells [HPP-CFCs]) and putative hematopoietic stem cells (HSCs; assayed in Dexter-type long-term culture). High concentrations of either compound (1) drastically reduced the number of primary HPP-CFC colonies and totally abolished their recloning capacity and (2) inhibited HSC proliferation. It is crucial that these results mirror recent observations indicating that murine adult HPCs transduced with dominant negative ATRA receptor (RAR) gene are immortalized and show a selective blockade of granulocytic differentiation. Altogether, these results suggest that ATRA/9-cis RA may play a key role in FL hematopoiesis via a dual effect hypothetically mediated by interaction with the RAR/RXR heterodimer, ie, inhibition of HSC/ primitive HPC proliferation and induction of CFU-GEMM/ BFU-E/CFU-M shift from the multipotent/erythroid/monocytic to the granulocytic-neutrophilic differentiation program.

Diagnostic pitfalls of echography in a case of hepatic cavernous hemangioma

An ecographic study of the liver in a 55-year-old female, with a history of mastectomy for a breast ductal cancer, showed multiple focal lesions. On computer tomography, we interpreted these lesions as metastatic disease. 99m Tc-labeled RBC showed non-homogeneous flow distribution in the right lobe of the liver. Fine needle aspiration biopsy under ecographic guidance showed no metastatic disease, and suggested a vascular lesion. The presence of spindle-shaped cells, reactive for CD 34 and for factor VIII, enabled definitive diagnosis of angiomatous lesion. Cytological confirmation of each hepatic mass is a mandatory prerequisite for any therapy.

Fetal liver generates low CD4 hematopoietic cells in murine stromal cultures

We have demonstrated that 0.2% to 11% of cells from the fetal liver (FL) reacted specifically with high concentrations of anti-CD4 monoclonal antibody (MoAb). CD4+ cells from FL were similar in surface phenotype and fluorescence characteristics to the CD4+ population found previously in adult bone marrow (BM). FL and BM cells were seeded in cultures that allow differentiation to primitive precursors. FL cells released many low CD4+ and low Thy+ cells in the supernatant, while BM cells seeded under the same conditions did not. We studied the nonadherent cells harvested from 10-day FL cultures (greater than 90% low CD4+). In methylcellulose, they were able to produce more colonies that appear to be characteristic of earlier stages in the hierarchy of hematopoietic precursors (especially erythroid bursts and colonies composed of both myeloid and erythroid elements) in comparison with CD4- cells from 10-day BM cultures. CD4+ cells harvested from FL cultures initiated secondary cultures containing both a stromal layer and large hematopoietic colonies when replated under conditions similar to those of primary cultures. Furthermore, a limited number of CD4+ cells from 10-day FL cultures were able to repopulate lethally irradiated mice. Although we cannot formally exclude the possibility that the low CD4 cells produced in FL cultures were derived exclusively from the proliferation of the few CD4 cells found in fresh FL, the dynamic analysis of the development of these cells in culture favors the generation of this important population from a CD4- subset of hematopoietic stem cells (HSCs). We speculate that FL contains a prevalent population of very primitive cells not expressing the CD4 antigen, tentatively called "pre-low CD4 precursors." These primitive cells can differentiate into low CD4+ cells that share many characteristics with pluripotent HSCs of the adult type. These data indicate the possibility of using hematopoietic progenitors obtained by the expansion/differentiation of fetal stem cells in culture for transplantation purposes.

Undifferentiated granulocytic sarcoma: a case with epidural onset preceding acute promyelocytic leukemia

This study reports a case of granulocytic sarcoma that developed in the epidural zone 25 days before clinical evidence of an acute promyelocytic leukemia. The case presented the diagnostic difficulties that are common to all aleukemic granulocytic sarcomas. Moreover, it highlights the very rare association between granulocytic sarcoma and acute promyelocytic leukemia, which is far from being explained.

[Prolymphocytic leukemia: the therapeutic strategy]

Prolymphocytic leukemia (PLL) is a malignant lymphoproliferative disorder, characterized by massive splenomegaly, predominance of prolymphocytes in the peripheral blood and bone marrow, minimal lymph nodes enlargement and poor prognosis. It accounts for a 5-10% case of chronic lymphocytic leukemia (CLL). Patients age is usually over the fifth decade, the disease is 4.1 more common in males. More than 80% are B-lymphocytic derived cells showing a post-thymic phenotype. Median survival of B-PLL patients is 3 years, while only 7 months in T-PLL. Standard therapy of CLL with alkylating agents and prednisone have been not much effective in the treatment of PLL with a response rate of about 20%. Up to date no ideal treatment is available for PLL. A realistic goal is probably to achieve a clinical course transformation, from aggressive to mild, thus changing from short to long term prognosis. For this purpose the initial therapeutic approach cannot be limited to a single agent only. Splenic irradiation, intensive anthracyclines-based regimens, leukapheresis combine together represent the best therapeutic choice. Alkylating agents with or without prednisone may play a role in keeping indolent clinical course. Fludarabine has shown antileukemic activity against PPL even in patients resistant.

Fetal tissue collection from spontaneous abortions: a report from a single centre

Due to immunological immaturity, the fetus is the ideal recipient as well as donor of haemopoietic stem cells (HSCs); thus intrauterine therapy may prove to be effective in all major haemopoietic disorders when early prenatal diagnosis is available. In man, "fetus-to-fetus" transplantation has demonstrated the possibility of grafting donor HSCs and reconstituting immunodeficient fetuses. The limitations of fetal tissue use for transplantation derive from the origin of tissues from elective abortions. Early and late live spontaneous abortions may constitute an alternative to elective abortions, but are widely considered as unsuitable for fetal tissue collection because of rapid loss of viability and/or infections. The aim of this retrospective study was to assess the number of live abortions in a population of women who underwent spontaneous abortion in a single centre. In a 19-month period, 9 spontaneous abortions alive at the moment of delivery and 8 with a heart beat at the last ultrasound scan before abortion were recorded. In 1 case, fetal liver (FL) harvesting was easily performed and the tissue was cryopreserved, subsequently thawed and injected into a monkey fetus. This case shows the feasibility of this approach. The majority of cases reviewed consisted of late abortions. These findings clearly show that fetal tissue collection from spontaneous abortions is feasible for research purposes, for postnatal FL transplantation and for intrauterine transplantation, postnatal FL transplantation and for intrauterine transplantation, provided that depletion of more mature cells is performed when FL of later gestational age are used.(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical delivery: comparison of two 5-year periods]

Operative delivery prevalence is considered in two periods: 1980-1985 and 1986-1990. Reduced prevalence of repeated cesarean section is reported for the second period as opposed to the first one. A larger prevalence of cesarean sections for anomalous presentation (breech presentation included), fetal distress. EPH gestosis, abruptio placentae is reported in the second half of '80's. Vacuum Extractor applications are reduced in the second period compared to the first one for with concern secondary uterine hypokinesia; larger V.E. applications are reported in the second period for fetal distress in the second stage of labor. Relatively rare forceps applications in both periods.

Comparison of fresh, cryopreserved and cultured haematopoietic stem cells from fetal liver

The cryopreservation and long-term culture of fetal liver (FL) cells may offer a ready source of haematopoietic stem cells (HSC). To compare these two techniques, an H-2-incompatible murine model was used, in conditions close to those of stem cell transplantation in humans. After cryopreservation, the recovery of colony-forming unit-culture (CFU-C) and of 14-day colony-forming unit-spleen (CFU-S) was 55.5% and 23%, respectively, compared with fresh cells. The rate of engraftment of donor cells was very high in mice reconstituted with either cryopreserved or fresh cells and the resulting chimerism was virtually complete in both cases. Functionally, both groups showed a significant humoral response to sheep red blood cells. Chimeric mice obtained by injection of cryopreserved cells were able to reject third-party SJL mouse (H-2s) skin grafts (11.4 +/- 1.6 days); at the same time, they specifically tolerated skin grafts from BDF1 (H-2b x H-2d) donor mice, indicating that cryopreserved FL cells could induce both tolerance to donor antigens and restore normal immunological responses to third-party alloantigens. Following 4-week cultures, consistent losses in the total number of CFU-C and CFU-S (2.5% and 8.6% yield, respectively) were observed. Cultured FL failed to protect the animals from the lethal effects of irradiation, due to insufficient reconstitution. These results favour the possible use of cryopreserved FL in clinical settings. At present, however, techniques to improve FL cultures and their efficiency for in vivo reconstitution are required.

[A case of intestinal obstruction in pregnancy]

Intestinal obstruction during pregnancy is a rare and dangerous complication. The causes of its occurrence are previous operations ad inflammation and one of their results: adhesions. Symptoms of intestinal obstruction (nausea, vomiting, constipation) rarely occur simultaneously and often accompany normal pregnancy, hampering diagnosis. Abdominal X-ray often represents the only complementary investigation diriment for diagnosis. A case of intestinal obstruction at 36 weeks gestation is reported to emphasize diagnostic difficulties of this rare pregnancy complication.

Retroperitoneal hemorrhage following bone marrow biopsy

We report the case of an elderly woman with polycythemia vera submitted to bone marrow biopsy who developed retroperitoneal hemorrhage as a result of direct penetration of the needle through the iliac crest, with damage to the iliolumbar artery, the first branch of the hypogastric artery.

[Evaluation of indications for cesarean section. Comparison of two decades. Preliminary results]

We have retrospectively analysed the incidence of cesarean section during the periods 1970-79 and 1981-90 and the evolution, if any, of the principal indication over time. The average incidence of cesarean section was 9.01% in the seventies and 11.63% in the eighties: the difference was statistically significant. Four classes of indication show significant differences between the periods considered: previous cesarean, feto-pelvic disproportion, anomalous presentation, gestosis. An evolution of cesarean section indications is shown: minus parity, better health, sanitary and environmental conditions, better physiopathological and clinical knowledge of pregnancy complication and labor seem to be causes of that evolution.

Early prenatal diagnosis and therapy of fetal hypothyroid goiter

We report a case of early diagnosis of iodide-induced fetal hypothyroidism at 22 weeks of gestation, confirmed at 29 weeks by cordocentesis and successfully treated intra-amniotically. The ultrasonographic feature was the presence of two echogenic masses in the fetal neck; polyhydramnios was absent. Mild hypothyroidism was diagnosed based on fetal serum obtained by percutaneous umbilical blood sampling at 29 weeks of gestation. The persistence of fetal hypothyroidism in spite of maternal thyroid improvement was confirmed by a second cordocentesis at 35 weeks of gestation, and a single injection of intra-amniotic levothyroxine (250 micrograms) was performed. The serial ultrasonographic examinations showed disappearance of the fetal goiter. A healthy female baby (3,630 g) was delivered at term. At birth, the thyroid gland was not enlarged, and neonatal thyroid hormones were within the normal range. This case suggests that cordocentesis is a reliable method to assess the fetal thyroid status; moreover a single injection of intra-amniotic thyroxine was effective in treating fetal hypothyroid goiter.