Determination and Management of Risks for Practices and Procedures in the Elderly (DRIPP): the impact of a comprehensive geriatric evaluation in elderly with diffuse large B-cell lymphoma

INTRODUCTION

Diffuse large B-cell lymphoma (DLBCL) treatment in older patients is challenging. The Determination and Management of Risks for Practices and Procedures in the Elderly (DRIPP) is a multidimensional evaluation program that involves patients undergoing oncological treatments.

OBJECTIVE

We aimed to evaluate the overall survival and progression-free survival (PFS) of patients evaluated and those not evaluated by the DRIPP.

MATERIALS AND METHODS

Retrospective cohort study, patients > 65 years with DLBCL were included. They were divided into 3 groups: patients with a diagnosis prior to the DRIPP implementation (pre-DRIPP), patients with the DRIPP (DRIPP) and patients with a diagnosis after the DRIPP implementation, but who did not undergo the evaluation (non-DRIPP).

RESULTS

A total of 125 patients were analyzed. Fourteen (11%) patients in the pre-DRIPP group, 74 (59%) in the DRIPP group, and 37 (30%) in the non-DRIPP group. In 43 (58%) patients of the DRIPP group, some drug dose adjustments were made vs. 19 (15%) in the non-DRIPP (p = 0.03). There were no significant differences in terms of discontinuation of treatment or hematological toxicity between groups. The OS and PFS in one year was 64% (95%CI 34-83) and 50% (95%CI 23-72) for the pre-DRIPP group, 82% (95%CI 71-89) and 72% (95%CI 60-81) for the DRIPP group, 58% (95% CI 41-72) and 56% (95% CI 38-70) for the non-DRIPP group, (p = 0.08). The analysis was adjusted for probable confounders and no differences were found.

CONCLUSIONS

This is the first study to evaluate the DRIPP as a decision-making tool in patients with lymphoma and showed a trend towards improvement in the OS in evaluated patients.

Single-center "Argentine" analysis of post-transplant lymphoproliferative disorders: incidence, histopathological characteristics and EBV status

INTRODUCTION

Post-transplant lymphoproliferative disorders (PTLDs) are a heterogeneous group of lymphoid proliferations occurring after solid organ or bone marrow transplantation. The primary aims of our study were to characterize cumulative incidence of PTLDs, clinical and pathological features according to the Epstein-Barr virus (EBV) status and survival.

METHODS

This was a retrospective cohort study on adult and pediatric patients, from January 2001 to December 2017. The cumulative incidence of PTLD was calculated by analyzing all the patients transplanted at our hospital, based on the database of the Organ Donation and Ablation Authority of Argentina (INCUCAI). The Kaplan-Meier method was used to plot the survival.

RESULTS

Fifty-eight cases of biopsy-confirmed PTLD were identified and 12 cases of clinical data were incomplete and these patients were excluded. The median age at the time of the PTLD diagnosis was 17.5 years (interquartile range [IQR] 9 - 57). The median interval between transplant and PTLD diagnosis was 39 months (IQR 9 - 113). The most commonly transplanted organ was the liver (24 cases, 52.2%), followed by kidney (20 cases, 43.5%). The Epstein-Barr encoding region in situ hybridization (EBER ISH) was positive in 29 (69.8%) of the 43 evaluable biopsies. The PTLD cumulative incidence was 1.84% (95%CI 1.77 - 1.91) for solid organ and 0.84% (95%CI 0.48 - 1.2) for bone marrow transplant patients. The overall survival rate at 5 years was 0.77 (95%CI 0.61 - 0.87). Subgroups by the EBV EBER status, transplant type, PTLD subtype and age group (adult vs. pediatric) showed no statistically significant association with the overall survival.

CONCLUSION

The PTLD incidence was similar to that of previous series and the EBER did not appear as a relevant factor in our patient survival.

[Classical nephroprotection: Renin angiotensin aldosterone system inhibitors]

The role of the renin angiotensin aldosterone system (RAAS) in the pathophysiology of hypertension, cardiovascular disease and kidney disease has been known for years. RAAS inhibitors have been the mainstay of chronic kidney disease (CKD) treatment. Studies have shown that therapy with angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensinII receptor blockers (ARBs) reduce the excretion of albuminuria and slow the progression of kidney disease in patients with and without diabetes. In clinical practice, RAAS inhibitors are recommended as the antihypertensive of choice in patients with CKD and albuminuria with or without diabetes. In addition, they have demonstrated cardiovascular benefits beyond blood pressure control. The use of RAAS inhibitors in non-proteinuric nephropathy and advanced CKD is not without controversy. Double blockade of the RAAS is contraindicated. On the other hand, it is essential to know how to titrate doses and avoid side effects, mainly hyperkalaemia.

Decrease in Mortality from Sepsis: Impact of the Multidisciplinary Program for the Hematologic Patient at Very High Risk

A program for the hematologic patient at very high risk of infections (HAR, from its initials in Spanish) was implemented, based on a multidisciplinary team and six measures intended to reduce the colonization and subsequent sepsis by multidrug-resistant organisms (MDRO). We aimed at evaluating the effectiveness of the HAR program in terms of MDRO infections mainly caused by Klebsiella pneumoniae carbapenemase-producing and multidrug-resistant Pseudomona aeruginosa, and sepsis-related mortality. We established retrospective comparisons between the pre-HAR period (2016-2018) and the post-HAR period (2018-2019), in patients who received a hematopoietic stem cell transplant (HSCT) and/or intensive chemotherapy to treat non-M3 acute myeloid leukemia (CH-AML). We included 262 patients: 176 pre-HAR and 86 post-HAR. MDRO infection was 4.6% at 30 days and 6.1% at 90 days (all the cases during the pre-HAR period). Sepsis-related mortality was 6.5%, considering a median follow-up of 608 days: 6.1% in the HSCT group and 12.4% in the CH-AML group (p = 0.306). Sepsis-related mortality was 8.7% in the pre-HAR period and 0% in the post-HAR period (p = 0.014). The implementation of this multidisciplinary program based in preventive measures and the appropriate use of antibiotics enabled a decrease in sepsis-related mortality in very high-risk hematologic patients.

Real-World Data on Adult T-Cell Leukemia/Lymphoma in Latin America: A Study From the Grupo de Estudio Latinoamericano de Linfoproliferativos

PURPOSE

Adult T-cell leukemia/lymphoma (ATLL) is an aggressive disease caused by the human T-cell leukemia virus type 1. Real-world data of ATLL in Latin America are lacking.

PATIENTS AND METHODS

We analyzed patients with ATLL (acute, lymphomatous, chronic, and smoldering) encountered in 11 Latin American countries between 1995 and 2019. Treatment response was assessed according to the 2009 consensus report. Survival curves were estimated using the Kaplan-Meier method and log-rank test.

RESULTS

We identified 253 patients; 226 (lymphomatous: n = 122, acute: n = 73, chronic: n = 26, and smoldering: n = 5) had sufficient data for analysis (median age 57 years). Most patients with ATLL were from Peru (63%), Chile (17%), Argentina (8%), and Colombia (7%). Hypercalcemia was positively associated with acute type (57% v lymphomatous 27%, P = .014). The median survival times (months) were 4.3, 7.9, 21.1, and not reached for acute, lymphomatous, chronic, and smoldering forms, with 4-year survival rates of 8%, 22%, 40%, and 80%, respectively. First-line zidovudine (AZT)-interferon alfa (IFN) resulted in an overall response rate of 63% (complete response [CR] 24%) for acute. First-line chemotherapy yielded an overall response rate of 41% (CR 29%) for lymphomatous. CR rate was 42% for etoposide, cyclophosphamide, vincristine, doxorubicin, and prednisone versus 12% for cyclophosphamide, vincristine, doxorubicin, and prednisone-like regimen (P < .001). Progression-free survival at 1 year for acute type patients treated with AZT-IFN was 67%, whereas 2-year progression-free survival in lymphomatous type patients who achieved CR after chemotherapy was 77%.

CONCLUSION

This study confirms Latin American ATLL presents at a younger age and has a high incidence of lymphomatous type, low incidence of indolent subtypes, and worse survival rates as compared with Japanese patients. In aggressive ATLL, chemotherapy remains the preferred choice for lymphomatous favoring etoposide-based regimen (etoposide, cyclophosphamide, vincristine, doxorubicin, and prednisone), whereas AZT-IFN remains a good first-line option for acute subtype.

Apoptotic regulator BCL-2 blockade as a potential therapy in classical Hodgkin Lymphoma

The challenge in classical Hodgkin Lymphoma (cHL) management is the 30-40% of refractory/relapsed cases.

AIMS

The aim of this work was to determine whether NIK and BCL-2 could be useful as prognosis biomarkers in cHL. In addition, we evaluated BCL-2 as a directed-therapy in cHL cell lines using venetoclax.

MAIN METHODS

We evaluated NIK and BCL-2 expression in 112 untreated cHL patients' lymph-node biopsies by immunohistochemistry. cHL cell lines were treated with venetoclax alone or combined with vincristine or doxorubicin. Cell viability, metabolic activity and cell death were analyzed by trypan-blue exclusion method, MTS assay and FDA/IP staining respectively.

KEY FINDINGS

No correlation between NIK or BCL-2 expression and the majority of the clinical parameters was found. Patients with ≥60% BCL-2+ HRS-cells had a shorter disease-free survival (DFS) and overall survival (OS) (p = 0.002, p = 0.02 respectively). A decision tree analysis, in a 30 patients subgroup, showed that patients with <60% NIK+ HRS-cells but with ≥60% BCL-2+ HRS-cells had a worse outcome in terms of DFS and OS. These parameters performed better as prognosis indicators as compared to the diagnosis bone marrow status. Human cHL cell lines U-H01, KM-H2, L1236, SUPHD1, L540 showed sensitivity to venetoclax. The co-treatment effect of venetoclax and vincristine or doxorubicin on cell viability was diverse depending on the cell line evaluated.

SIGNIFICANCE

BCL-2 should be considered as a prognosis biomarker as well as a potential new therapeutic target in cHL. We report for the first time the cytotoxic effect of venetoclax in human cHL cell lines.

EBER+ extranodal NK/T lymphoma in patient with idiopathic CD4 lymphocytopenia

Idiopathic CD4 lymphocytopenia (ICL) not related to HIV is an infrequent and severe condition with no etiology defined until now. The concomitant presence of an underlying disease, especially an oncohematological process, could be related to the immune physiopathology and the development of the immunosuppressive state. On the other hand, Epstein Barr virus is a well-known oncogenic pathogen described in the development of several types of lymphoma which might be reactivated in the ICL. There is still no specific treatment for this syndrome, so the therapeutic scope for these patients is the treatment of opportunistic diseases and the administration of specific antimicrobials as prophylaxis. We present a patient with an uncommon association of an ICL and an extranodal T/NK lymphoma with detection of VEB nuclear RNA by in situ hybridization (EBER). Diagnosis was challenging which led the health team to carry out many studies over several months.

Acquired factor XIII deficiency in patients under therapeutic plasma exchange: A poorly explored etiology

INTRODUCTION

Factor XIII (FXIII) deficiency may cause bleeding under certain clinical circumstances. Therapeutic plasma exchange (TPE) may lead to a transient deficiency.

OBJECTIVES

To describe the clinical evolution of patients with acquired FXIII deficiency secondary to TPE.

METHODS

We respectively studied a cohort of consecutive patients from 2014 to 2019 who were treated with TPE with FXIII levels <50%. The FXIII was measured after the start of the TPE course, on days between the TPE sessions, due to suspected acquired deficiency. All TPE were performed using continuous flow cell separator. In all cases, the initial replacement fluid applied was albumin. Apheresis procedures were held at 24to 48 hours intervals.

RESULTS

Eighteen patients were included, 13 of them were recipients of kidney transplants. The main TPE prescription was humoral rejection. Median FXIII at diagnosis (measured on days between sessions of the TPE course) was 19%(IQR17-25). The median of apheresis procedures before measurement of FXIII was 3(IQR2-4). Among the total cohort, 10 patients suffered hemorrhages. None of the patients without history of kidney transplants had bleeding (n = 5), however, 10/13 with kidney transplants did. Five kidney transplant patients received therapy with FXIII concentrate because of life-threatening bleeding. In all cases, the bleeding stopped within the first 24 hours. All patients had their FXIII levels measured again after finishing the TPE course, with normal results.

CONCLUSIONS

TPE is an under-diagnosed cause of acquired FXIII deficiency since routine coagulation tests remain unaltered. It might cause major bleeding, particularly in patients with a recent history of surgery like kidney transplants.

Abstract 6235: BCL2 blockade in refractory and relapsed classic Hodgkin Lymphoma; Venetoclax sensitize cells to first line treatment

Classic Hodgkin Lymphoma (cHL) is a germinal center derived lymphoma with 9,000 new cases diagnosed each year in the US. Despite 70-80% early stage cHL patients respond to current systemic treatment, 10% of patients are refractory to first-line therapy and 30-40% relapse. Refractory and relapsed disease is currently the challenge when treating cHL patients. There are no biomarkers suitable to identify patients that would be refractory or that could relapse at the primary diagnosis. Furthermore, there is no specific therapy rather than rescue chemotherapy schemes, which fails in 50% of the cases and associates with high risk severe toxicity. This highlights the need to deeper understand the cHL molecular biology and the screening for prognosis biomarkers and therapeutic innovative approaches.

We have previously reported that the alternative NFkB pathway, mediated by Rel-B and NIK (NFkB Inducing Kinase), plays an important role in cHL survival. Its constitutive activation sustains high BCL2 expression.

We analyzed NIK and BCL2 citoplasm expression in Hodgkin Reed-Sternberg cells (HRS) in the lymph node biopsies of 112 cHL naïve of therapy patients by immunohistochemistry [51 female Md age and (range) 36 (6-88), 61 male 40.7 (9-78)]. The median follow-up period was 512, months (6 to 136 months).

The univariate analysis showed no correlation between NIK or BCL2 expression and the prognosis clinical and pathological parameters, including the PET Scan indicated at the end of the first-line treatment, neither the molecular markers routinely assayed. The statistical significance was maintained in multivariate analysis (Logistic and Cox Regression p=0.01).

The survival analysis, using the Kaplan-Meir curves, showed that patients with ≥60% positive HRS cells had a shorter disease-free survival (DFS) [Log Rank Test (Mantel Cox) p=0.002] and a reduced overall survival (OS) [Log Rank Test (Mantel Cox) p=0.02]. NIK expression did not correlate with prognosis.

L1236, U-H01, KM-H2, SUPDH1 and L540 human cHL cell lines that express BCL2 protein, were sensitive to venetoclax a specific BCL2 inhibitor. The drug induced cell cycle arrest in S-Phase and G2-M when treated with 1uM each 24 hours during 10 days, as compared to wild type cells and cells treated with the vehicle. Furthermore, venetoclax sensitized cHL cell lines to vincristine and doxorubicin, two drugs used in the first-line chemotherapy scheme ABVD (Adriamycin, Bleomycin, vincristine, doxorubicin).

In summary, we found that the alternative NFkB pathway plays an important role in the refractory and relapsed Hodgkin disease biology, being BCL2 a key downstream target. BCL2 performed well as a prognosis biomarker identifying refractory patients and those that relapsed being assayed at diagnosis of the primary disease. We believe BCL2 directed-therapy in cHL could be interested in

patients that express this protein in ≥60% HRS cells in the lymph node biopsy performed at diagnosis. Furthermore venetoclax sensitized cHL cells to conventional chemotherapy.

Citation Format: Angélica M. Cedeño-Gamboa, Mariángeles Díaz, Victoria Otero, Natalia Schutz, Dorotea Fantl, Federico Jauk, Myriam Nuñez, Stella M. Ranuncolo. BCL2 blockade in refractory and relapsed classic Hodgkin Lymphoma; Venetoclax sensitize cells to first line treatment [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 6235.

Complete remission and proviral load negativization after allogeneic-SCT in a patient with Adult T-cell lymphoma: Case report

Adult T-cell lymphoma is an aggressive and poor prognosis HTLV1-associated lymphoma. There is no standard treatment, but it is known that intensive chemotherapy regimens are necessary, with or without concomitant antiretroviral therapy, plus consolidation with allogeneic stem cell transplantation. Our case report shows a favorable outcome after 2 cycles of chemotherapy and allogeneic stem cell transplantation without antiretroviral agents, achieving complete remission, and a negative proviral load.

[Ileitis as presentation of lymphoma in Wiskott-Aldrich syndrome]

Wiskott-Aldrich syndrome is a rare X chromosome-linked primary immunodeficiency syndrome associated with an increased incidence of infections, autoimmune disorders and neoplasms. We present the case of a 41-year-old man with a diagnosis of Wiskott-Aldrich syndrome with ileitis as a form of presentation of a lymphoproliferative syndrome. The ileitis, in the context of the patient, represents a clinical challenge given the large number of differential diagnoses (inflammatory bowel disease, infections, neoplasms and lymphoproliferative diseases), so it usually requires anatomopathological diagnosis and particular considerations regarding the subsequent specific treatment.

Abstract 4032: The alternative NF-kB pathway activity in refractory and relapsed Hodgkin lymphoma

The refractory and relapsed disease is currently the challenge in Hodgkin Lymphoma (HL) treatment. There is no specific therapy but rescue chemotherapy schemes, which fails in 50% of the cases and associates with high risk severe toxicity. This highlights the need to deeper understand the HL molecular biology and the screening for therapeutic directed-targets.

We have previously reported that HL relies on the alternative NFkB pathway, mediated by Rel-B and NIK, to survive. Its constitutive activation seems to be involved in the refractory and relapsed disease.

To determine the specific Rel-B target genes we performed ChIP-Seq in UH01 and L1236 human HL cell lines for Rel-A, Rel-B, cRel, p50 and p52. We found 29,414 Rel-B peaks genome-wide distributed. To further identify genes with higher probabilities of being directly regulated by Rel-A, Rel-B, and/or cRel we concentrated on the peaks that localized within a +/- 2 kb window, relative to the gene transcription start site. The +/- 2 kb Rel-B peaks were distributed on 4,509 genes; meanwhile the +/- 2 kb cRel peaks were on 1,994 genes and the Rel-A peaks were on 830 genes. Out of the 4,509 genes with the Rel-B peaks, only 6% overlapped with the Rel-A peaks and 11% with the cRel peaks. The Rel factors distribution showed a Rel-B DNA-binding hierarchy in HL.

The ChIP-Seq data were merged with gene expression arrays results. The gene expression assays were analyzed by comparing the signal from cells infected with noninduced shRNAs for the Rel factors to that from cells infected with induced shRNAs. Differentially expressed genes were identified via ANOVA analysis. Genes that were downregulated more than 2-fold with a p&lt;0.001 were considered significant. We found that the Rel-B downstream controlled gene set was enriched for cell cycle and cell death regulation and DNA damage and repair signatures, among others.

One of the exclusively Rel-B target genes was BCL2. We showed that exogenous BCL2 was able to partially rescue HL cells from dying in response to Re-B depletion. We also found that BCL2 was useful as a prognosis marker in terms of overall survival in a cohort of 96 HL patients [Log Rank Test (p=0.002)]. In this retrospective study [follow up period 47,4 (6-136) months], BCL2 was able to identify at diagnosis patients that were refractory to conventional first line treatment and patients that relapsed. The HL cell lines U-H01, L1236, SUPDHL1, KM-H2 and L540 were sensitive to the BCL2 inhibitor venetoclax. The HDM-2 cell line, which does not express BCL2, was a good control of target specificity since it did not die in response to venetoclax.

In summary, we found that the alternative NFkB pathway plays an important role in the refractory and relapsed Hodgkin disease, being BCL2 a key downstream target. BCL2 performed well as a prognosis marker identifying refractory patients and those that would relapse. We propose BCL2 expression assessment in the lymph node biopsy at diagnosis and BCL2 as a directed therapy.

Citation Format: Angélica María Gamboa-Cedeño, Mariángeles castillo, Victoria Otero, Natalia Schutz, Dorotea Fantl, Federico Jauk Vitali, Hernán García Rivello, Myriam Nuñez, Stella Maris Ranuncolo. The alternative NF-kB pathway activity in refractory and relapsed Hodgkin lymphoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4032.

Abstract 766: Refractory and relapsed predictive biomarkers in Hodgkin lymphoma and potential directed-therapy targets

Despite 90% stage I Hodgkin Lymphoma (HL) patients can respond to current therapy, this drops to 60% when diagnosed in late stages. Nevertheless and independently of the lymphoma stage, the real challenge when treating these patients, is the refractory and relapsed disease. There is no biomarker to identify patients that would be non-responsive to conventional treatment or that would relapse. Furthermore, rescue chemotherapy schemes for refractory and relapsed patients, associate with acute and late toxicity high risk. This highlights the need to deeper understand the HL molecular biology and the screening for predictive biomarkers as well as potential therapeutic directed-targets. We have previously reported that HL relies on the alternative NFkB pathway, mediated by relB and NIK, to survive. Depletion of either RelB or NIK by shRNAs or pharmacological NIK inhibitors induce HL cell death. ChIP-Seq analysis uncovered relB target genes showing relB bound to BCL2 promoter. A significant downregulation of BCL2 mRNA and bcl2 protein levels, following relB or NIK knockdown was observed, indicating relB regulation. Our molecular studies suggested that NFkB alternative pathway constitutive signaling could at least partially explain the non-responding HL cases. We aimed to analyze whether mediators of this pathway could be useful as predictive biomarkers and would represent potential targetable factors in both refractory and relapsed patients. We analyzed NIK and bcl2 citoplasm expression in Hodgkin Reed-Sternberg cells (HRS) in lymphatic node biopsies of 96 patients by inmunohistochemistry [50 female Md age and (range) 59 (6-82), 46 male 42 (9-78)]. The univariate analysis showed no correlation between NIK or bcl2 expression and the prognosis clinical and pathological parameters, neither the molecular markers routinely assayed. A positive correlation was found between NIK and bcl2 expression (p=0.01). NIK and bcl2 correlated with lack of response to conventional therapy and both early and late disease progression. The analysis of survival, applying the Kaplan-Meier Curves, showed &gt; 60% NIK positive HRS cells associated with shorter Disease Free Survival (DFS) [Log Rank Test (p=0.000)] and predicted overall survival (OS) as well [Log Rank Test (p=0.01)]. Furthermore, &gt; 60% bcl2 positive HRS cells correlated with poor prognosis in terms of OS [Log Rank Test (p=0.002)]. The statistical significance was maintained in the multivariate analysis [Cox Regression and Logistic Regression (p=0.001)]. NIK and bcl2 performed successfully as useful predictive markers to identify refractory or risk of relapse HL patients at diagnosis. They represent attractive molecules to further analyse their potential as directed-therapy targets, since we have already reported that HL is sensitive to NIK inhibitors and bcl2 blockers have already been approved for clinical use in other hematological pathologies.

Citation Format: Angélica M. Gamboa-Cedeño, Victoria Otero, Natalia Schutz, Dorotea Fantl, Hernán Rivello, Federico Jauk-Vitali, Myriam Nuñez, Stella Maris Ranuncolo. Refractory and relapsed predictive biomarkers in Hodgkin lymphoma and potential directed-therapy targets [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 766.

A little key to oxalate formation in oil paints: protective patina or chemical reactor?

A novel degradation mechanism for 19^th c. chrome yellow oil paints is proposed based on the oil photodegradation induced and calcium oxalate formation. It was proved by synchrotron radiation using artificially aged pigment reconstructions.

[Hemophagocytic lymphohistiocytosis. Experience in 27 patients]

BACKGROUND

Hemophagocytic lymphohistiocytosis (HLH) is an aggressive and life-threatening syndrome of excessive immune activation Aim: To describe the clinical characteristics, causes and survival associated with HLH.

MATERIAL AND METHODS

Review of medical records of patients with HLH attended between 2004 and 2016. They were classified according to their probable cause in: associated with immunosuppression, cancer, post-infectious or idiopathic. Kaplan-Meier survival analysis was performed.

RESULTS

Twenty seven patients with HLH aged 18 to 87 years (59% men), were detected. Fourteen (52%) were secondary to immunosuppression, six (22%) were post-infectious, five (18%) were associated with cancer and two (7%) were of unknown cause. There were no significant differences in clinical or laboratory features between these etiologies. Within the immunosuppressed group, 12 (86%) were patients with oncologic or hematologic diseases or bone marrow transplantation. Associated cancers were mostly oncohematologic diseases. Thirty-day mortality was 53.4% (95% confidence intervals (CI) 32.7-70.3%), despite the treatment. Mortality was significantly associated with the presence of renal failure with a hazard ratio (HR) of 3.4 (95% CI of 1.2-9.9, p =0.025). Treatment of the underlying disease proved to be protective against mortality with an HR of 0.3 (95% CI 0.1 to 0.98, p = 0.046).

CONCLUSIONS

The prognosis of HLH could be related to the treatment of the underlying disease. The study of the pathophysiology of this syndrome will allow a better understanding and treatment.

[Renal function and plasma dabigatran level measured at trough by diluted thrombin time assay]

Dabigatran etexilate (direct thrombin inhibitor) is effective in preventing embolic stroke in patients with atrial fibrillation. It does not require laboratory control, but given the high renal elimination, its measurement in plasma is important in renal failure. The objectives of the study were to verify the analytical quality of the diluted thrombin time assay for measurement of dabigatran plasma concentration (cc), correlate cc with classic coagulation assays, prothrombin time (PT) and activated partial thromboplastin time (APTT), and evaluate them according to the creatinine clearance (CLCr). Forty plasma samples of patients (34 consecutive and 6 suspected of drug accumulation) receiving dabigatran at 150 (n = 19) or 110 (n = 21) mg/12 hours were collected. Blood samples were drawn at 10-14 hours of the last intake. Dabigatran concentration was determined by diluted thrombin time (HemosIl DTI, Instrumentation Laboratory (IL). PT and APTT (IL) were performed on two fotooptical coagulometers, ACL TOP 300 and 500 (IL). DTI presented intra-assay coefficient of variation < 5.4% and inter-assay < 6%, linearity range 0-493 ng/ml. Patients' cc: median 83 (4-945) ng/ml. Individuals with CLCr in the lowest tertile (22.6-46.1 ml/min) showed significantly higher median cc: 308 (49-945), compared to the average 72 (12-190) and highest tertile, 60 (4-118) ng/ml. Correlation between cc and APTT or PT were moderate, r2 = 0.59 and -0.66, p < 0.0001, respectively. DTI test allowed us to quantify plasma dabigatran levels, both in patients with normal or altered renal function, representing a useful tool in clinical situations such as renal failure, pre surgery or emergencies.

Microplastics in coastal sediments from Southern Portuguese shelf waters

Microplastics are well-documented pollutants in the marine environment that result from fragmentation of larger plastic items. Due to their long chemical chains, they can remain in the environment for long periods of time. It is estimated that the vast majority (80%) of marine litter derives from land sources and that 70% will sink and remain at the bottom of the ocean. Microplastics that result from fragmentation of larger pieces of plastic are common to be found in beaches and in the water surface. The most common microplastics are pellets, fragments and fibres. This work provides original data of the presence of microplastics in coastal sediments from Southern Portuguese shelf waters, reporting on microplastic concentration and polymer types. Microplastic particles were found in nearly 56% of sediment samples, accounting a total of 31 particles in 27 samples. The vast majority were microfibers (25), identified as rayon fibres, and fragments (6) identified as polypropylene, through infrared spectroscopy (μ-FTIR). The concentration and polymer type data is consistent with other relevant studies and reports worldwide.

[Treatment conditioning variables in elderly patients with acute myeloid leukemia. An institutional experience]

Patients over 60 years old with acute myeloid leukemia (AML) have a worse prognosis due to several factors that determine the therapeutic outcome. The main predictors of mortality in patients with AML reported in the literature were analyzed in our population. The primary objective was to analyze overall survival. The secondary objective was to determine treatment-related mortality, defined as death within eight weeks of starting treatment. It was designed as a retrospective study. A total of 133 treatment naive patients were included, from January 1991 to August 2014. The adjusted analysis showed that the most important variables to determine overall survival were the WBC count = 30 000 at diagnosis [adjusted HR 2.19 (1.06-4.53), p = 0.03)] and the Performance Status (ECOG) 3 or 4 [aHR 4.63 (1.69-12.68), p < 0.001)]. Performance Status 3-4 was the only variable that conditioned treatment related mortality, showing in the univariate analysis an OR 5.44 (CI 1.93-15.28, p < 0.001). It was also the only variable that kept its statistical power in the multivariate analysis adjusted OR (aOR) 12.40 (IC 1.12-137.17, p = 0.04). The inherent poor outcome in elderly patients diagnosed with AML is not fully understood. The best way of assessing these elderly patients should probably include not only age but the best way of assessing these elderly patients should probably include not only age but laboratory, genetic and molecular studies. Especially designed comorbidity and fragility indices should be included, along with functional status. Leukocytosis and poor quality of life were identified as the most powerfull factors for predicting mortality in our study.

Evidence of microplastics in samples of zooplankton from Portuguese coastal waters

Records of high concentrations of plastic and microplastic marine debris floating in the ocean have led to investigate the presence of microplastics in samples of zooplankton from Portuguese coastal waters. Zooplankton samples collected at four offshore sites, in surveys conducted between 2002 and 2008, with three different sampling methods, were used in this preliminary study. A total of 152 samples were processed and microplastics were identified in 93 of them, corresponding to 61% of the total. Costa Vicentina, followed by Lisboa, were the regions with higher microplastic concentrations (0.036 and 0.033 no. m⁻³) and abundances (0.07 and 0.06 cm³ m⁻³), respectively. Microplastic: zooplankton ratios were also higher in these two regions, which is probably related to the proximity of densely populated areas and inputs from the Tejo and Sado river estuaries. Microplastics polymers were identified using Micro Fourier Transformed Infrared Spectroscopy (μ-FTIR), as polyethylene (PE), polypropylene (PP) and polyacrylates (PA). The present work is the first report on the composition of microplastic particles collected with plankton nets in Portuguese coastal waters. Plankton surveys from regular monitoring campaigns conducted worldwide may be used to monitor plastic particles in the oceans and constitute an important and low cost tool to address marine litter within the scope of the Marine Strategy Framework Directive (2008/56/EC).

Analysis and redesign of a knowledge database for a drug-drug interactions alert system

Physicians tend to ignore drug-drug interactions alerts, this is due to the large amount of irrelevant interactions displayed and the interface in which these alerts are shown. The high rate of clinically inadequate alerts produce "alerts fatigue". This high number of incorrect alerts predisposes physicians to underestimate the electronic prescription systems as useful tools in their practice. We decided to analyze and redesign our drug-drug interactions alerting system knowledge database. In order to do so, we cleaned our knowledge database according to the clinical significance of drug-drug interactions. New drug interactions taxonomy was created in four levels based on clinical significance and the recommendations given in each single monograph of interaction. We proceeded to recategorize the alerts as Active, which present themselves to the physician interrupting the prescribing process, or Passive, which allow physicians to accept the recommendations, and adopt some action in order of minimizing the interaction risks.

Authentic cell-specific and developmentally regulated expression of pro-opiomelanocortin genomic fragments in hypothalamic and hindbrain neurons of transgenic mice

The pro-opiomelanocortin (POMC) gene is expressed in a subset of hypothalamic and hindbrain neurons and in pituitary melanotrophs and corticotrophs. POMC neurons release the potent opioid beta-endorphin and several active melanocortins that control homeostasis and feeding behavior. POMC gene expression in the CNS is believed to be controlled by distinct cis-acting regulatory sequences. To analyze the transcriptional regulation of POMC in neuronal and endocrine cells, we produced transgenic mice carrying POMC27*, a transgene containing the entire 6 kb of the POMC transcriptional unit together with 13 kb of 5' flanking regions and 8 kb of 3' flanking regions. POMC27* was tagged with a heterologous 30 bp oligonucleotide in the third exon. In situ hybridization studies showed an accurate cell-specific pattern of expression of POMC27* in the arcuate nucleus and the pituitary. Hypothalamic mRNA-positive neurons colocalized entirely with beta-endorphin immunoreactivity. No ectopic transgenic expression was detected in the brain. Deletional analyses demonstrated that neuron-specific expression of POMC transgenes required distal 5' sequences localized upstream of the pituitary-responsive proximal cis-acting elements that were identified previously. POMC27* exhibited a spatial and temporal pattern of expression throughout development that exactly paralleled endogenous POMC. RNase protection assays revealed that POMC27* expression mimicked that of POMC in different areas of the CNS and most peripheral organs with no detectable ectopic expression. Hormonal regulation of POMC27* and POMC was identical in the hypothalamus and pituitary. These results show that distal 5' sequences of the POMC gene located between -13 and -2 kb target expression into the CNS of transgenic mice in a precise neuron-specific, developmentally and hormonally regulated manner.

Accurate spatial and temporal transgene expression driven by a 3.8-kilobase promoter of the bovine beta-casein gene in the lactating mouse mammary gland

The spatial, temporal, and hormonal pattern of expression of the beta-casein gene is highly regulated and confined to the epithelial cells of the lactating mammary gland. Previous studies have shown that 1.7 kb of the bovine beta-casein promoter were able to drive cell-specific and hormone-dependent expression to a mouse mammary cell line but failed to induce accurate expression to the mammary gland of transgenic mice. We investigated here the ability of 3.8 kb of the bovine beta-casein gene promoter to drive the expression of the human growth hormone (hGH) gene in transgenic mice. A Northern blot analysis using total RNA obtained from different tissues of lactating and nonlactating females revealed the presence of hGH mRNA only in the mammary gland of lactating females. hGH mRNA was not detectable in the mammary gland of virgin females or males. A developmental analysis showed that hGH mRNA only peaked on parturition, resembling more closely the bovine beta-casein temporal expression pattern rather than the murine. In situ hibridization studies performed on mammary gland sections showed that the cellular pattern of hGH expression was homogeneous in all lobules from heterozygous and homozygous transgenic mice. Silver grain counts on the tissue sections highly correlated with the hGH contents in the milk determined by radioimmunoassay (r = 0.996). Thus 3.8 kb of the bovine beta-casein promoter direct a high-level expression of a reporter gene to the lactating mammary gland of transgenic mice in a tissue-specific and developmentally regulated manner.