A potential role of fetal hemoglobin in the development of multidrug resistance

Our previous data from a human leukemic cell line made resistant to the nucleoside analog (NA) 9-β-D-arabinofuranosylguanine (AraG) revealed a massive upregulation of fetal hemoglobin (HbF) genes and the ABCB1 gene coding for the multidrug resistance P-glycoprotein (P-gp). The expression of these genes is regulated through the same mechanisms, with activation of the p38-MAPK pathway and inhibition of methylation making transcription factors more accessible to activate these genes. We could show that AraG, as well as other NAs, and P-gp substrates could induce global DNA demethylation and induction of Hbγ and P-gp both at the mRNA and protein expression level. We speculate that the expression of HbF prior to drug exposure or in drug-resistant cell lines is a strategy of the cancer to gain more oxygen, and thereby survival benefits. We also believe that P-gp may be induced in order to excrete Hb degradation products from the cells that would otherwise be toxic. By using Hbγ siRNA and pharmacological inhibitors of HbF production we here present a possible relationship between HbF induction and multi-drug resistance in a human leukemia cell line model.

Fetal haemopoiesis marking low-grade urinary bladder cancer

BACKGROUND

The immunohistochemical features of fetal haemoglobin cells and their distribution patterns in solid tumours, such as colorectal cancer and blastomas, suggest that fetal haemopoiesis may take place in these tumour tissues. These locally highly concentrated fetal haemoglobin (HbF) cells may promote tumour growth by providing a more efficient oxygen supply.

METHODS AND RESULTS

Biomarkers of HbF were checked in transitional cell carcinoma (TCC) of the urinary bladder, assessing this as a new parameter for disease management. Fetal haemoglobin was immunohistochemically examined in tumours from 60 patients with TCC of the bladder. Fetal haemoglobin erythrocytes and erythroblasts were mainly clonally distributed in proliferating blood vessels and not mixed with normal haemoglobin erythrocytes. The proportion of such HbF blood vessels could reach more than half of the total number of vessels. There were often many HbF erythroblasts distributed in one-cell or two-cell capillaries and present as 5-15% of cells in multi-cell vessels. This suggests a local proliferation of HbF-cell progenitors. Fetal haemoglobin cells were prominently marking lower grades of tumours, as 76% (n=21) of the patients with G1pTa were HbF+, whereas only 6.7% (n=30) of the patients with G3pT1-pT2a were HbF+.

CONCLUSION

Our results suggest that HbF, besides being a potential new marker for early tumour detection, might be an essential factor of early tumour development, as in fetal life. Inhibiting HbF upregulation may provide a therapeutic target for the inhibition of tumour growth.

Foetal haemoglobin-blood cells (F-cells) as a feature of embryonic tumours (blastomas)

Tumour markers are important in the diagnosis and monitoring of many tumours. This study tested the hypothesis that an oncofoetal protein, foetal haemoglobin (HbF) is a potential tumour marker in embryonic tumours, useful for management. An immunohistochemical investigation of HbF blood cell (Fc) distribution was carried out in tumours and in bone marrow samples from 83 children and 13 adults with various embryonic tumours (blastomas), and in bone marrow samples of 24 leukaemia patients. In the three, main blastoma types, nephroblastoma (Wilms' tumour), neuroblastoma and retinoblastoma, where all the patients, except two, were children, around 80% of the tumour samples had Fc within proliferating blood vessels and spaces between tumour cells. In parallel, clusters of Fc, mostly F-erythroblasts (Feb), were distributed in the bone marrow of some of those patients and in the bone marrow of 79% of the leukaemia patients. Foetal haemoglobin, as well as being a potential prognostic cancer marker, is a potential indicator of DNA hypomethylation implicated in the development of these tumours, as well as in others previously noted for the presence of HbF.

Development of fetal haemoglobin-blood cells (F cells) within colorectal tumour tissues

AIM

To evaluate the sources of fetal haemoglobin (HbF) as an indicator in cancer. An immunohistochemical study was carried out on some of the most common kinds of cancer. All of these cancers had serologically high levels of HbF as evaluated previously.

METHODS

Immunoaffinity-purified anti-HbF was immunohistochemically used to study F cell distribution in the following cancers: colorectal adenocarcinoma, urinary bladder transitional cell carcinoma, brain tumours, lung carcinoma, breast adenocarcinoma, leukaemia, Burkitt's lymphoma and endometrial carcinoma.

RESULTS

In colorectal adenocarcinoma, HbF-containing red blood cells (FRBC) were present within thin-walled vessels or were disposed in dense clusters within the tumour. Some of these cells were nucleated or binucleated HbF-erythroblasts or HbF-normoblasts (FNBS). In two cases, high levels of mitoses within HbF-erythroblasts were observed. In half of the cases with transitional cell carcinoma of the urinary bladder, regional intratumoral blood vessels were found to contain 5-50% FRBC. In the other tumours examined, F cells were not observed. FRBCs, however, were occasionally observed in the regional lymph nodes of some of these cancers.

CONCLUSIONS

The evaluation of HbF as a potential plasma marker is suggested by the high concentration of FRBCs in colorectal tumours. The apparent development of FRBCs in colorectal tumour tissues is an interesting observation, as these cells were previously thought to develop in medullary or lymphoid tissues. It is thus suggested that the colonic microenvironment may stimulate extramedullary fetal-type haematopoiesis.

Blood cells with fetal haemoglobin (F-cells) detected by immunohistochemistry as indicators of solid tumours

AIMS

Fetal hemoglobin (HbF) is an established serological indicator of cancer. However, its distribution in tumour tissues is rarely investigated. Therefore, HbF was studied immunohistologically in different cancers characterised by high blood HbF concentrations.

METHODS

Anti-HbF was immunoaffinity purified and used to study HbF immunohistochemically in the following cancers: germ cell tumour (GCT), trophoblastic disease (TD), lymphoma, myelodysplastic syndrome (MDS), multiple myeloma (MM), and ovarian adenocarcinoma (OA).

RESULTS

In GCT a distinction was made between tumours substantially without HbF positive red blood cells (F-RBC) and those with F-RBC. Those without F-RBC were non-metastatic mature teratomas and dermoid cysts. Those containing F-RBC were mainly embryonal carcinomas and metastatic teratomas. HbF positive myeloid cells (F-MLC), HbF positive normoblasts (F-NBS), and F-RBC were common in the bone marrow and in the lymphoid tissues of lymphoma, MDS, and MM. In TD, normal and nucleated F-RBC were seen in the trophoblastic villi in one case with incomplete molar pregnancy (ICM) but not in other cases of ICM and complete molar pregnancy. However, F-RBC and F-MLC were seen in the decidua of both types of TD. Generally, F-cells were observed either within blood vessels or concentrated in certain areas of the neoplastic tissue.

CONCLUSIONS

HbF was evaluated as an inducible marker within different tumour tissue blood cells. The dual distribution of these cells-circulating in the blood or concentrated in areas of the neoplastic tissues-might reflect the two independent serological indicators of HbF: one in whole blood and the other in plasma of patients with cancer.

[Multiresistant Escherichia coli from elderly patients]

We examined all ceftriaxone-resistant Escherichia coli isolates obtained from clinical samples during 16 months (1 Dec. '97-31 Mar. '99). A total of 97 resistant isolates from 36 patients were obtained, mostly from urine specimens. Of these patients, 35/36 were over 75 years old, most lived in nursing homes, were dependent on nursing in their daily lives, and were incontinent and/or had indwelling catheters. All 97 isolates had similar susceptibility profiles: resistant to ciprofloxacin, gentamicin, ampicillin, amoxycillin/clavulanate, tricarcillin/clavulanate, aztreonam, and cefuroxime; decreased susceptibility to ceftazidime and cefepime; and susceptible to imipenem and meropenem. Double-disc tests indicated that all strains produced extended spectrum beta-lactamase(s). All the isolates belonged to 1 of 3 E. coli serotypes: 79 were 0153:H31, 13 were 0142:H10, and 5 were 0102:H6.

Enterotoxigenic Escherichia coli (ETEC) in hospitalised Arab infants from Judea area--west bank, Israel

Enterotoxigenic Escherichia coli and other related enterotoxigenic species were isolated from 176 (44%) of 399 infants hospitalised in 'Caritas Baby Hospital' in Bethlehem, during April-December 1993. Ninety four of the patients infected by ETEC, were clinically evaluated. Most of them suffered from diarrhoea, quite often with fever and vomiting. Dehydration occurred in 58.3% of the patients and failure to thrive (FTT) in 28.5% of them. Severe illness resulted in marasmus in five patients and in the death of two others. Most of the ETEC strains (84%) were of ST toxin type. Correlation was found between the degree of toxigenity and the severity of the gastroenteritis. The most prevalent ETEC "O' serogroups were 0-6, 0-20, 0-8, 0-86, 0-126, 0-128 and 0167. Colonization Factors Antigens (CFAs) were identified in 36% of the isolates, CFAI was characteristic of group 0-126 and 0-128. In the principal O-groups there were high percentages of sensitivity to the antibiotics ceftriaxone, nalidixic-acid, gentamicin and norfloxacin, with resistance to anoxycillin, tetracycline and cotrimoxazole.

Whither the PRO? Analysis of the effectiveness of three Medicare peer review organizations in a Florida hospital

The objective of this retrospective study was to evaluate the effectiveness of a peer review organization (PRO) on patient mortality rate in a not-for-profit, 988-bed community hospital in Florida. The number of deaths per hospital discharge (mortality) was compared prior to the Professional Foundation for Health Care (PFHC) holding the contract as the Medicare PRO (1983), during two years in which the PRO was fully active (1990 and 1991), during the year limited PRO activities were conducted (1992), and when PRO activities were again fully expanded (1993). All Medicare hospital discharges, including deaths, were included from January through May during 1983, 1990 through 1993. There was no intervention. Patient mortality as a determinant of PRO effectiveness was evaluated prior to the PRO, during a portion of the years the PFHC held the contract as the Medicare PRO, and an identical time period one year later with limited PRO review and again the following year when full reviews returned. The number of deaths did not change significantly. Mandated peer reviews of care to inpatient hospital Medicare beneficiaries did not significantly improve health care as measured by mortality.

Association between high concentration of antibodies to insulin and some diseases common in the elderly

Antibodies to insulin (IA) were measured by graded hemagglutination in 164 patients and in 90 control subjects aged 18-65 years. The greatest prevalence of these antibodies was found in patients with the organic mental syndrome, of whom 70% (n = 110) had an antibody concentration above the normal 95th percentile. Among patients with diabetes, hypertension and cerebrovascular accidents, 42% had a high concentration of IA, while in all other geriatric patients (n = 21) the concentration of these antibodies was within the normal range.

Fetal hemoglobin screening in whole blood and in plasma of cancer patients

Fetal hemoglobin (HbF) screening was performed on 296 cancer patients. In almost 80% of the patients with active disease (n = 197) and 35-60% of those with inactive disease (n = 99), the concentration of HbF in the blood was above the normal range. Among patients with metastatic breast carcinoma (n = 27), 89% had a high HbF concentration. The HbF level was significantly higher (p less than 0.001) in patients with active disease than in those with inactive disease. There is evidence of an ectopic production of HbF into the plasma of patients, but it will be necessary to develop a method for the prevention of hemolysis in order to establish this claim.

[A thermostable toxin-producing E. coli and infantile diarrhea]

An E. coli strain producing only a thermostable toxin (ST) and belonging to serogroup 0153 (ETEC 0153; ST) was isolated from the stools of 9 infants with diarrhea, 4 of them premature, during the last half of August, 1988. All the 4 prematures passed frequent fluid stools. In 5 of the 9 infants, other pathogens were found in addition to the ETEC strain, including rotavirus, Plesiomonas and Shigella sonnei. Until recently, ETEC strains like that described were considered rare all over the world. During the past 2 years ETEC strains belonging to that serogroup and toxin type were reported as a major cause for infantile diarrhea in Spain in 5 outbreaks. Infantile diarrhea caused by an ETEC strain in Israel is reported here for the first time.

Percutaneous cardiopulmonary bypass to support angioplasty and valvuloplasty. Technical considerations

To eliminate problems during percutaneous transluminal coronary angioplasties (PTCAs) or valvuloplasties (PV), percutaneous cardiopulmonary bypass (PCPB) was used in 19 high-risk patients (pts) to perform supported PTCA (12 pts, age 40-68) for low EF and/or a large area of risk (L main), and supported PV (7 pts, age 68-92) for "nonoperative" candidates with severe AS. Our experience promoted a review of the technical aspects of PCPB was needed for a successful outcome in these high-risk patients. All patients were treated with IV amnestics while awake in the catheter laboratory. Early in the experience, 20F arterial and venous cannulas were inserted via a 2 cm cutdown in the right groin; now 17F arterial and 20F venous cannulas are placed via a Seldinger technique using fluoroscopy. Traversement of the iliac vein is enhanced by a roll under the buttocks. If the artery is calcified, a cutdown, vessel loops, and direct repair are employed to assure post-PCPB patency. Total flows of 6L/min are easily achieved with nonreservoir centrifugal pump bypass. If flow or pressures fall, 200 cc of blood or crystalloid rapidly improves venous drainage and flows and unlike during reservoir bypass, alpha agonists are only rarely necessary; CaCl often produces nausea in these patients. PCWP's are brought to 0-5 mm Hg. Due to the 1,500 cc priming volume, on-pump transfusion is often required. Two patients were successfully transported to the OR on PCPB for treatment of catheter failures. With attention to technical details, percutaneous bypass supported PTCA or PV is an important new therapy for high risk patients.

Evaluation of fetal hemoglobin in various malignancies with reference to the patients' age

Concentration of fetal hemoglobin (HbF) was measured in the blood of 172 cancer patients with solid tumors. The patients' age groups were compared with matched age groups of normal controls. Above the age of 50, a significant difference was found between patients and normal controls. In 70% of the patients with active disease, the concentration of HbF was above the normal range. There were indications that by reducing HbF concentrations irradiation of patients interferes with the evaluation of the results. In addition to whole blood, HbF was also measured in the plasma of 35 patients; the average HbF concentration in this group was found to be twice as high as that of the controls.

Improved haemagglutination reagent for detecting antibodies to insulin in diabetic and non-diabetic young and old patients

A stable reagent of insulin-coated erythrocytes was developed for easy measurement of antibodies to insulin. For this measurement, the principle of graded haemagglutination (GH) was successfully applied. All of 100 healthy, young- to middle-aged controls, had no detectable antibodies. The incidence of antibodies was not higher in diabetic patients injected with highly purified porcine insulin, than in those not injected. A high incidence of antibodies to insulin was found among chronic elderly patients, amounting to 41% of the symptomatically non-diabetic and 77% of the diabetic.

Graded hemagglutination inhibition for quantification of human fetal hemoglobin

We describe a hemagglutination system for quantification of fetal hemoglobin (HbF), especially at low concentrations. This system consists of three components: (a) sheep erythrocytes coated with purified HbF, (b) sheep antiserum of human HbF made specific for the gamma-chain, and (c) human blood lysate with a known concentration of HbF as the standard. We can measure the whole range of HbF proportions in human blood, from 100% down to 0.01%. Statistical analysis showed that our measurements agreed with those made by the methods of alkali denaturation and radial immunodiffusion. Reproducibility of the method is shown by the low CVs for six repeated measurements. Low concentrations of HbF not measurable by other methods are easily assayed. We offer examples of the clinical utility of data on low concentrations of HbF.

Graded hemagglutination inhibition for quantification of human fetal hemoglobin

We describe a hemagglutination system for quantification of fetal hemoglobin (HbF), especially at low concentrations. This system consists of three components: (a) sheep erythrocytes coated with purified HbF, (b) sheep antiserum of human HbF made specific for the gamma-chain, and (c) human blood lysate with a known concentration of HbF as the standard. We can measure the whole range of HbF proportions in human blood, from 100% down to 0.01%. Statistical analysis showed that our measurements agreed with those made by the methods of alkali denaturation and radial immunodiffusion. Reproducibility of the method is shown by the low CVs for six repeated measurements. Low concentrations of HbF not measurable by other methods are easily assayed. We offer examples of the clinical utility of data on low concentrations of HbF.

Continuing medical education in New York County: physician attitudes and practices

New York County physicians were surveyed by questionnaire concerning their attitudes and practices regarding continuing medical education (CME). There were 1,558 responders, and they included those practicing in shared health facilities (SHF) and random samples of academicians on the faculties of the four medical schools and of the entire physician population of Manhattan. Reading professional books and journals was regarded as by far the most important CME activity by all three groups of physicians, and this activity consumed about four hours per week. All physicians spent several days and often as much as two weeks per year attending professional meetings and formal postgraduate courses. The former were rated as not very useful and the latter as quite useful for CME. Major impediments to CME participation for all groups were time away from home and practice, expense, loss of income, and scheduling problems. Relevance, quality, and organization of CME courses were not major impediments. SHF physicians differed little from other physicians in their attitudes, perceptions, and practices concerning CME.

Evaluation of standard curves in the graded hemagglutination-inhibition method applied to quantitation of human immunoglobulins

For accurate quantitation of human immunoglobulins A and B by graded hemagglutination inhibition, I have established standard curves. For IgA, plotting the inner diameter of the ring formed by sedimented erythrocytes vs the log of the antigen concentrations gives a straight line. Plotting the same parameters for IgG gives a hyperbolic line. These ratios between antigen concentration and ring diameter were constant for at least one year. Both undiluted and 10,000-fold diluted human serum may be quantitated by this method, depending only on immunoglobulin concentrations. Precision (CV) of the system, assessed in 35 patients’ sera over the period of one year, ranged from 0.5 to 15.2% (mean 10%) for IgA and from 1.4 to 14.9% (mean 7.3%) for IgG.

Evaluation of standard curves in the graded hemagglutination-inhibition method applied to quantitation of human immunoglobulins

For accurate quantitation of human immunoglobulins A and B by graded hemagglutination inhibition, I have established standard curves. For IgA, plotting the inner diameter of the ring formed by sedimented erythrocytes vs the log of the antigen concentrations gives a straight line. Plotting the same parameters for IgG gives a hyperbolic line. These ratios between antigen concentration and ring diameter were constant for at least one year. Both undiluted and 10,000-fold diluted human serum may be quantitated by this method, depending only on immunoglobulin concentrations. Precision (CV) of the system, assessed in 35 patients' sera over the period of one year, ranged from 0.5 to 15.2% (mean 10%) for IgA and from 1.4 to 14.9% (mean 7.3%) for IgG.

Evaluation of standard curves in the graded hemagglutination-inhibition method applied to quantitation of human immunoglobulins

For accurate quantitation of human immunoglobulins A and B by graded hemagglutination inhibition, I have established standard curves. For IgA, plotting the inner diameter of the ring formed by sedimented erythrocytes vs the log of the antigen concentrations gives a straight line. Plotting the same parameters for IgG gives a hyperbolic line. These ratios between antigen concentration and ring diameter were constant for at least one year. Both undiluted and 10,000-fold diluted human serum may be quantitated by this method, depending only on immunoglobulin concentrations. Precision (CV) of the system, assessed in 35 patients’ sera over the period of one year, ranged from 0.5 to 15.2% (mean 10%) for IgA and from 1.4 to 14.9% (mean 7.3%) for IgG.

Unstable angina pectoris: national cooperative study group to compare medical and surgical therapy. I. Report of protocol and patient population

A preliminary report is presented of a prospective randomized trial conducted by eight cooperative institutions under the auspices of the National Heart and Lung Institute to compare the effectiveness of medical and surgical therapy in the management of the acute stages of unstable angina pectoris. To date 150 patients have been included in the randomized trial, 80 assigned to medical and 70 to surgical therapy; the clinical presentation, coronary arterial anatomy and left ventricular function in the two groups are similar. Some physicians have been reluctant to prescribe medical or surgical therapy by a random process, and the eithical basis of the trial has been questioned. Since there are no hard data regarding the natural history and outcome of therapy for unstable angina pectoris, randomization appears to provide a rational way of selecting therapy. Furthermore, subsets of patients at high risk may emerge during the process of randomization. The design of this randomized trial is compared with that of another reported trial. Thus far, the study has shown that it is possible to conduct a randomized trial in patients with unstable angina pectoris, and that the medical and surgical groups have been similar in relation to the variables examined. The group as a whole presented with severe angina pectoris, either as a crescendo pattern or as new onset of angina at rest, and 84 percent had recurrence of pain while in the coronary care unit and receiving vigorous medical therapy. It is anticipated that sufficient patients will have been entered into the trial within the next 12 months to determine whether medical or surgical therapy is superior in the acute stages of unstable angina pectoris.

Cerebrospinal fluid acidosis complicating therapy of experimental cardiopulmonary arrest

Cardiopulmonary resuscitation (CPR) may be followed by slow recovery of brain function. The possible role of bicarbonate therapy was assessed by analysis of arterial blood and cerebrospinal fluid (CSF) in 20 dogs during cardiac arrest and CPR. Samples were taken in the control period and every 5 minutes post-arrest of 20 minutes. Group I received no post-arrest CPR. Arterial pH fell from 7.37 to 7.31 (P less than 0.01) and CSF pH from 7.34 to 6.94 (P less than 0.001). Arterial pCO2 rose from 39 to 65 mm Hg (P less than 0.005) and CSF pCO2 increased from 47 to 123 (P less than 0.02). With CPR alone (group II) arterial pH decreased from 7.39 to 7.19 (P less than 0.005), while arterial pCO2 and CSF pH and pCO2 were undhanged. CPR with bicarbonate therapy (mEq = weight in kg times 0.43 times 1.1 mEq/min of arrest) given every 5 minutes (group III), resulted in a rise in arterial pH from 7.41 to 7.81 (P less than 0.02). Excess bicarbonate administration during CPR may result in a marked dissociation between arterial and CSF pH as a consequence of rapid CO2 diffusion across the blood-brain barrier. Large ampounts of NaHCO3 given during CPR may contribute to post-CPR cerebral depresssion.