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Dhingra R, He F, Saunders EF, Waschbusch DA, Pearl AM, Bixler EO, Greaney JL, Al-Shaar L, Chinchilli VM, Yanosky JD, Liao D. Abstract P249: Moderate-to-Severe Depression Symptoms Are Associated With Poorly Controlled Glucose Levels in Persons With Type 2 Diabetes Mellitus. Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Objective:
To investigate whether the severity of depression symptoms is associated with poor long-term control of plasma glucose levels in individuals with type 2 diabetes.
Methods:
Electronic health record [EHR] data of 2842 individuals with mental illness enrolled in the Penn State Clinical Assessment and Rating Evaluation System [PCARES] registry were used. Demographics, body mass index [BMI], baseline type 2 diabetes mellitus [T2DM] status and all available glucose labs were extracted from the EHR. The nine-item patient health questionnaire [PHQ-9] was used to determine baseline depression symptoms. PHQ-9 scores greater than/equal to 10 indicated moderate-to-severe depression symptoms, whereas scores less than 10 indicated none-to-mild depression symptoms. While the baseline glucose measurement had to be within ± 90 days of the baseline PHQ-9 date, longitudinal glucose measurements had to be on or after this date and within one year of the second follow-up glucose lab test date. Each glucose lab test had to be within one year of the preceding lab test. There were 917 individuals that met the criteria for baseline and follow-up glucose measurements and contributed to the effective study sample. Linear mixed-effects models were used to assess the association between baseline depression and changes in glucose levels, with a focus on persons with baseline diabetes. Results are reported as beta-coefficients (standard errors [SE]) and
P
-values.
Results:
The study sample included 917 individuals, with 65% females (596 of 917) and 85% (780 of 917) Non-Hispanic Caucasians. The mean (SD) age, PHQ-9 score, BMI, and glucose were 47.7 (16.9) years, 12.0 (7.1), 31.6 (8.6) Kg/m
2,
and 115.9 (48.8) mg/dl, respectively. At baseline, 62.0% had moderate-to-severe depression (569 of 917), and 37.1% of persons had T2DM (341 of 917). Among individuals without T2DM, there was no association between the severity of depression symptoms and follow-up glucose levels with a beta (SE) of 1.1 (1.1) and
P
=0.32. Among persons with T2DM (N=341), there was an average increase in glucose levels by 2.8 (2.1) mg/dl,
P
=0.17, per year of follow-up. When stratified by the severity of depression symptoms, individuals with moderate-to-severe depression symptoms had a significant increase in glucose levels at 6.2 (2.7) mg/dl,
P
=0.02, per year of follow-up, indicative of poor control of blood glucose levels. Whereas, among persons with none-to-mild depression symptoms, blood glucose levels showed a non-significant decline at 2.6 (3.4) mg/dl,
P
=0.45, per year of follow-up.
Conclusions:
In this clinic-based sample of persons with mental illness, moderate-to-severe depression symptoms were associated with significantly increasing blood glucose levels among persons with co-morbid T2DM. Our findings underscore integrated physical and mental healthcare services and routine depression screening among persons with diabetes.
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Affiliation(s)
| | - Fan He
- Penn State College of Medicine, Hershey, PA
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2
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Darling AM, Mogle J, Fadel PJ, Saunders EF, Almeida DM, Greaney JL. A Potential Link Between Negative Affective Responsivity to Daily Stress and Blood Pressure Reactivity to Acute Stress in College‐Aged Adults. FASEB J 2022. [DOI: 10.1096/fasebj.2022.36.s1.r4181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Paul J. Fadel
- KinesiologyThe University of Texas at ArlingtonArlingtonTX
| | - Erika F. Saunders
- Psychiatry and Behavioral HealthPenn State College of MedicineHersheyPA
| | - David M. Almeida
- Human Development and Family StudiesThe Pennsylvania State UniversityUniversity ParkPA
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3
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Grotle A, Darling AM, Saunders EF, Fadel PJ, Greaney JL, Trott DW. Inflammatory phenotype and T‐cell mitochondrial reactive oxygen species in young adults with major depressive disorder. FASEB J 2022. [DOI: 10.1096/fasebj.2022.36.s1.r3913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Erika F. Saunders
- Department of Psychiatry and Behavioral HealthPenn State University Hershey Medical CenterHersheyPA
| | - Paul J. Fadel
- KinesiologyUniversity of Texas at ArlingtonArlingtonTX
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Grotle AK, Darling AM, Saunders EF, Fadel PJ, Trott DW, Greaney JL. Augmented T-cell mitochondrial reactive oxygen species in adults with major depressive disorder. Am J Physiol Heart Circ Physiol 2022; 322:H568-H574. [PMID: 35179977 PMCID: PMC8917910 DOI: 10.1152/ajpheart.00019.2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 11/22/2022]
Abstract
The prevalence of major depressive disorder (MDD) is highest in young adulthood, an effect that has been magnified by the COVID-19 pandemic. Importantly, individuals with MDD are at a greater risk of developing cardiovascular disease (CVD). Accumulating evidence supports immune system dysregulation as a major contributor to the elevated CVD risk in older adults with MDD; however, whether this is present in young adults with MDD without comorbid disease remains unclear. Interestingly, recent data suggest augmented T-cell mitochondrial reactive oxygen species (T-cell mitoROS) as a potent driver of immune dysregulation in animal models of psychiatric disease. With this background in mind, we tested the hypothesis that young adults with MDD would have augmented T-cell mitoROS and circulating proinflammatory cytokines compared with healthy young adults without MDD (HA). Whole blood was drawn from 14 young adults with MDD (age: 23 ± 2 yr) and 11 HA (age: 22 ± 1 yr). T-cell mitoROS (MitoSOX red; total: CD3+, T-helper: CD4+, T cytotoxic: CD8+) and serum cytokines were assessed by flow cytometry. Total T-cell mitoROS was significantly greater in adults with MDD compared with HA [median: 14,089 arbitrary units (AU); median: 1,362 AU, P = 0.01]. Likewise, both T-helper and T-cytotoxic cell mitoROS were significantly greater in adults with MDD compared with HA (both: P < 0.05). There were no differences in circulating cytokines between groups (all cytokines: P > 0.05). Collectively, these findings suggest that elevated T-cell mitoROS may represent an early marker of immune system dysregulation in young, otherwise healthy, adults with MDD.NEW & NOTEWORTHY To our knowledge, we provide the first evidence of augmented T-cell mitochondrial reactive oxygen species (T-cell mitoROS) in young, otherwise healthy adults with MDD. Although the elevated T-cell mitoROS did not correspond to a proinflammatory profile, these findings suggest that elevated T-cell mitoROS may be an early marker of immune system dysregulation in young adults with MDD.
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Affiliation(s)
- Ann-Katrin Grotle
- Department of Kinesiology, University of Texas at Arlington, Arlington, Texas
| | - Ashley M Darling
- Department of Kinesiology, University of Texas at Arlington, Arlington, Texas
| | - Erika F Saunders
- Department of Psychiatry and Behavioral Health, Penn State College of Medicine, and Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Paul J Fadel
- Department of Kinesiology, University of Texas at Arlington, Arlington, Texas
| | - Daniel W Trott
- Department of Kinesiology, University of Texas at Arlington, Arlington, Texas
| | - Jody L Greaney
- Department of Kinesiology, University of Texas at Arlington, Arlington, Texas
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5
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Dhingra R, He F, Saunders EF, Waschbusch DA, Pearl AM, Mukherjee D, Bixler EO, Greaney JL, Liao D. Abstract 060: Cardiovascular Disease Burden In A Psychiatric Outpatient Population. Circulation 2021. [DOI: 10.1161/circ.143.suppl_1.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
To understand the burden of cardiovascular diseases (CVDs) in a psychiatric outpatient population.
Methods:
We used baseline data from the ongoing Penn State Psychiatry Clinical Assessment and Rating Evaluation System (PCARES) Registry, which is comprised of adult patients who were seen at a psychiatric outpatient clinic affiliated with the Department of Psychiatry and Behavioral Health and the Penn State Milton S. Hershey Medical Center. The Electronic Medical Record (EMR) data from 3,024 patients who sought psychiatric care between 02/17/2015 and 09/18/2019 were included in this report. We compared the prevalence of CVDs and the mean levels of major CVD risk factors in our sample with that reported in the 2013-2016 National Health and Nutrition Examination Survey (NHANES).
Results:
The mean age of the study population was 42.7 (16.7) years, with 63% female and 85% Caucasians. The most common psychiatric diagnoses at baseline were Major Depressive Disorder [ICD-10: F32 & F33] (45%), Generalized Anxiety Disorder [ICD-10: F41.1] (20%), and Bipolar Disorder [ICD-10: F31] (12%). Eighteen percent of patients reported using tobacco products and 1.7% reported using alcohol. The prevalence (%) of CVDs, type 2 diabetes, hypertension, and dyslipidemia in our sample were 9.1, 20, 48, and 41%, respectively (all significantly higher than the NHANES reports, all p < 0.0001). The baseline means (mg/dl) of total cholesterol (C), LDL-C, HDL-C, and triglycerides (TG) were 186, 108, 48, and 156, respectively (all are significantly lower than that reported from the NHANES, except for TG, which was higher than that of the NHANES, all p < 0.0001), while 22% of all patients had prescriptions for lipid-lowering medications. Baseline mean level of glucose and HbA1C were 111 mg/dl and 6.2% (both significantly higher than that from the NHANES, p < 0.0001).
Conclusions:
In this systematic registry of psychiatric outpatients from a mid-Atlantic academic medical center, the baseline CVD burden as measured by common cardiovascular diseases, comorbidities and risk factors are significantly higher than the CVD burden in the general US population. Considering that the mean age of this patient population is 5 years younger than that of the NHANES population, our data underscores the need for control and prevention of CVD in patients with psychiatric conditions, and suggests the potential of integrating mental and physical health care in this type of special population.
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Affiliation(s)
| | - Fan He
- PENN STATE COLLEGE OF MEDICINE, Hershey, PA
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6
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Sanjana F, Richey RE, DeConne TM, Saunders EF, Brothers RM, Martens CR, Greaney JL. The role of depressive symptoms on brain blood vessel pulsatility in humans. FASEB J 2020. [DOI: 10.1096/fasebj.2020.34.s1.09656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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7
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Greaney JL, Santhanam L, Saunders EF, Alexander LM. Mechanisms of Endothelial Dysfunction in Young Adults with Major Depressive Disorder: Influence of Sex. FASEB J 2018. [DOI: 10.1096/fasebj.2018.32.1_supplement.710.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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8
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Greaney JL, Koffer RE, Saunders EF, Almeida DM, Alexander LM. Self‐Reported Everyday Psychosocial Stressors are Associated with Greater Impairments in Endothelial Function in Young Adults with Major Depressive Disorder. FASEB J 2018. [DOI: 10.1096/fasebj.2018.32.1_supplement.737.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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9
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Prossin AR, Chandler M, Ryan KA, Saunders EF, Kamali M, Papadopoulos V, Zöllner S, Dantzer R, McInnis MG. Functional TSPO polymorphism predicts variance in the diurnal cortisol rhythm in bipolar disorder. Psychoneuroendocrinology 2018; 89:194-202. [PMID: 29414032 PMCID: PMC6048960 DOI: 10.1016/j.psyneuen.2018.01.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/11/2018] [Accepted: 01/17/2018] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Psychosocial stress contributes to onset/exacerbation of mood episodes and alcohol use, suggesting dysregulated diurnal cortisol rhythms underlie episodic exacerbations in Bipolar Disorder (BD). However, mechanisms underlying dysregulated HPA rhythms in BD and alcohol use disorders (AUD) are understudied. Knowledge of associated variance factors have great clinical translational potential by facilitating development of strategies to reduce stress-related relapse in BD and AUD. Evidence suggests structural changes to mitochondrial translocator protein (TSPO) (a regulator of steroid synthesis) due to the single nucleotide polymorphism rs6971, may explain much of this variance. However, whether rs6971 is associated with abnormal HPA rhythms and clinical exacerbation in humans is unknown. METHODS To show this common TSPO polymorphism impacts HPA rhythms in BD, we tested whether rs6971 (dichotomized: presence/absence of polymorphism) predicted variance in diurnal cortisol rhythm (saliva: morning and evening for 3 days) in 107 BD (50 with and 57 without AUD) and 28 healthy volunteers of similar age and ethno-demographic distribution. RESULTS Repeated measures ANOVA confirmed effects BD (F5,525 = 3.0, p = 0.010) and AUD (F5,525 = 2.9, p = 0.012), but not TSPO polymorphism (p > 0.05). Interactions were confirmed for TSPO × BD (F5,525 = 3.9, p = 0.002) and for TSPO × AUD (F5,525 = 2.8, p = 0.017). DISCUSSION We identified differences in diurnal cortisol rhythm depending on presence/absence of common TSPO polymorphism in BD volunteers with or without AUD and healthy volunteers. These results have wide ranging implications but further validation is needed prior to optimal clinical translation.
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Affiliation(s)
- Alan R Prossin
- Department of Psychiatry, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA; Houston Methodist Research Institute, Houston, TX, USA.
| | - Matthew Chandler
- Department of Psychiatry, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Kelly A Ryan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Erika F Saunders
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Psychiatry, Medical School, Penn State College of Medicine and the Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Masoud Kamali
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | | | - Sebastian Zöllner
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Robert Dantzer
- Department of Symptom Research, Division of Internal Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Melvin G McInnis
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
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10
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Saunders EF, Lampkin BC, Mauer AM. Variation of proliferative activity in leukemic cell populations of patients with acute leukemia. J Clin Invest 2010; 46:1356-63. [PMID: 16695924 PMCID: PMC297137 DOI: 10.1172/jci105628] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In 31 children with acute leukemia, the proliferative activity of the leukemic marrow cell population as measured by mitotic and labeling indexes varied widely from patient to patient and from one disease stage to another. Leukemic marrow had a small but statistically significant diurnal variation of proliferative activity. Changes in labeling indexes were directly related to changes in the proportion of large dividing blasts in the marrow. Generation times of dividing leukemic blast cells in 3 patients were similar at diagnosis and in relapse. Changes in proliferative activity of leukemic marrow can be explained by progressive accumulation of nondividing leukemic cells.
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Affiliation(s)
- E F Saunders
- Department of Pediatrics, University of Cincinnati, The Children's Hospital, and The Children's Hospital Research Foundation, Cincinnati, Ohio
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11
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Gassas A, Sung L, Saunders EF, Doyle J. Graft-versus-leukemia effect in hematopoietic stem cell transplantation for pediatric acute lymphoblastic leukemia: significantly lower relapse rate in unrelated transplantations. Bone Marrow Transplant 2007; 40:951-5. [PMID: 17873916 DOI: 10.1038/sj.bmt.1705853] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
To determine graft-versus-leukemia (GVL) effect after hematopoietic stem cell transplantation (HSCT), we studied the outcome of consecutive children with acute lymphoblastic leukemia (ALL) who received fully matched marrow allografts comparing relapse rate post HSCT between matched sibling donor (MSD) and matched unrelated donor (MUD) recipients. Furthermore, we estimated event-free survival (EFS) on the basis of the occurrence of acute graft-versus-host disease (aGVHD). Between 1998 and 2006 we performed 37 fully MSD and 36 fully MUD HSCTs. All patients received identical conditioning regimens with cyclophosphamide/total body irradiation and dual GVHD prophylaxis with cyclosporine (CSA) and methotrexate (MTX). Three-year cumulative incidence of relapse for the MSD and MUD groups were 55.6+/-12.3 and 22.0+/-8.1%, respectively (P=0.03). Three-year EFS according to aGVHD was 32.7+/-12.2% for no aGVHD, 61.2+/-10.0% for grade I-II aGVHD and 66.7+/-11.1% for grade III-IV aGVHD. Three-year EFS and overall survival (OS) were 40.5+/-11.6, 49.1+/-9.5% for the MSD group, and 60.5+/-8.7, 62.3+/-8.4% for the MUD group. In children with ALL receiving dual GVHD prophylaxis, relapse rate is significantly higher among recipients of MSD compared to MUD transplantation, which may in part be attributed to a better GVL effect with the unrelated graft.
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Affiliation(s)
- A Gassas
- Division of Hematology/Oncology/Bone Marrow Transplantation, The Hospital for Sick Children, University of Toronto, Ontario, Canada.
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12
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Gassas A, Sung L, Saunders EF, Doyle JJ. Conditioning regimens for ALL allografts. Bone Marrow Transplant 2007. [DOI: 10.1038/sj.bmt.1705596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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13
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Gassas A, Sung L, Saunders EF, Doyle JJ. Comparative outcome of hematopoietic stem cell transplantation for pediatric acute lymphoblastic leukemia following cyclophosphamide and total body irradiation or VP16 and total body irradiation conditioning regimens. Bone Marrow Transplant 2006; 38:739-43. [PMID: 17013424 DOI: 10.1038/sj.bmt.1705515] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
To compare the outcome of hematopoietic stem cell transplantation (HSCT) in pediatric acute lymphoblastic leukemia (ALL) conditioned with two different regimens: (1) single dose of VP16 (60 mg/kg over 4 h) and total body irradiation (TBI; 1200 cGy, in six fractions) or (2) Cyclophosphamide 50 mg/kg over 1 h daily for 4 days followed by the same dose of TBI. One hundred and seven children with ALL received fully matched HSCT from 1990 to 2003 in the Hospital for Sick Children, Toronto. All received cyclosporin A and a short course of methotrexate for graft-versus-host disease (GVHD) prophylaxis. The VP16 group, there were 36 matched related donor transplants (MRD) and 26 matched unrelated donor transplants (MUD), and in the cyclophosphamide group there were 23 MRD and 22 MUD transplants. Neutrophil engraftment occurred at a median of 18 and 17 days for the VP16/TBI and the CY/TBI groups, respectively. The 3 year event-free survival and overall survival were 47 +/- 7 and 55 +/- 7% for those receiving VP16/TBI, and 51 +/- 8 and 53 +/- 8% for the CY/TBI group. There were no significant differences in the prevalence of acute or chronic GVHD and transplant-related mortality between the two groups. Both VP16/FTBI and CY/FTBI regimen are equally effective regimens.
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Affiliation(s)
- A Gassas
- Division of Hematology/Oncology/Bone Marrow Transplantation, The Hospital for Sick Children, University of Toronto, Ontario, Canada.
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14
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Sharathkumar A, Saunders EF, Dror Y, Grant R, Greenberg M, Weitzman S, Chan H, Calderwood S, Freedman MH, Doyle J. Allogeneic bone marrow transplantation vs chemotherapy for children with Philadelphia chromosome-positive acute lymphoblastic leukemia. Bone Marrow Transplant 2003; 33:39-45. [PMID: 14566329 DOI: 10.1038/sj.bmt.1704319] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Allogeneic bone marrow transplant (BMT) with an MRD in complete remission (CR)1 is the preferred treatment for children with Philadelphia-positive (Ph(+)) ALL. The role of MUD BMT in CR1 is still controversial. We compared the outcomes of two treatment strategies: BMT using an MRD or MUD vs chemotherapy in children with Ph(+) ALL in CR1. In total, 21 children were treated from 1985 to 2001. In all, 10 received chemotherapy and 11 received allogeneic BMT: four MRD, seven MUD. In the MRD group, one relapsed 12 months after BMT and died; the remaining three are long-term event-free survivors (median follow-up, 6.1 years). In the MUD group four died; the remaining three are long-term event-free survivors (median follow-up, 7.2 years). The 4-year event-free survival (EFS) for the BMT group was 53+/-15%. In the chemotherapy group, seven relapsed after a median period of 12.5 months and three remain in continuous CR (median follow-up, 2.4 years). Four chemotherapy patients received CR2 transplants; all died. The 4-year EFS for the chemotherapy and MUD groups was 33+/-17 and 35.7+/-20%, respectively. This difference was not statistically significant. We continue to support treating children with Ph(+) ALL with MRD BMT in CR1. The effectiveness of MUD BMT vs chemotherapy merits further study.
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Affiliation(s)
- A Sharathkumar
- The Hospital for Sick Children, Division of Hematology/Oncology, University of Toronto, Toronto, Canada
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15
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16
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Kusnierczyk NMA, Saunders EF, Dupuis LL. Outcomes of antiemetic prophylaxis in children undergoing bone marrow transplantation. Bone Marrow Transplant 2002; 30:119-24. [PMID: 12132051 DOI: 10.1038/sj.bmt.1703579] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2001] [Accepted: 02/06/2002] [Indexed: 11/09/2022]
Abstract
A prospective survey of the control of acute and delayed antineoplastic and radiation-induced nausea and vomiting was undertaken in children undergoing bone marrow transplantation (BMT) at The Hospital for Sick Children. Prior administration of antineoplastic agents or irradiation, presence of anticipatory nausea or vomiting prior to starting the conditioning regimen, antiemetic use within 24 h of conditioning, the prescribed antineoplastic and/or radiation ablative regimen, and prescribed antiemetic regimens were recorded. Emetic episodes, dietary intake, administration of conditioning agents and antiemetics, and adverse effects were monitored on each day of the conditioning regimen and for 96 h thereafter. Children older than 3 years of age assessed their nausea on each study day. Twenty-five children were followed for 258 patient days. Children did not vomit or retch on 73% and 43% of patient days, in the acute and delayed phases, respectively. Nausea data were evaluable for 21 children on 200 patient days. Nausea was absent on 55% and 26% of patient days in the acute and delayed phases, respectively. Five children never had an emetic episode during the entire study period. One child was completely free from nausea and vomiting throughout the study period. Antineoplastic and radiation-induced nausea and vomiting can be successfully prevented in the majority of children undergoing BMT. However, effective treatment strategies must be developed in the event of antiemetic failure and for effective prophylaxis in children who cannot tolerate dexamethasone.
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Affiliation(s)
- N M A Kusnierczyk
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada
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17
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Al-Kasim FA, Thornley I, Rolland M, Lau W, Tsang R, Freedman MH, Saunders EF, Calderwood S, Doyle JJ. Single-centre experience with allogeneic bone marrow transplantation for acute lymphoblastic leukaemia in childhood: similar survival after matched-related and matched-unrelated donor transplants. Br J Haematol 2002; 116:483-90. [PMID: 11841456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Seventy percent of children with acute lymphoblastic leukaemia (ALL) who may benefit from bone marrow transplant (BMT) lack a human leucocyte antigen (HLA)-matched related donor (MRD). For these children, BMT from a matched unrelated donor (MUD) represents a therapeutic option. We reviewed the course of 62 children with ALL who received fully matched marrow allografts at our institution between 1990 and 1998: 36 with MRDs and 26 with MUDs. Clinical characteristics were similar in the two groups. The interval from attainment of pre-BMT complete remission to transplant was significantly longer in the MUD group. Conditioning (etoposide/total body irradiation) and graft-versus-host disease (GVHD) prophylaxis regimens were the same for all patients, and all received T cell-replete bone marrow. There was no significant difference in probability of engraftment, or time to engraftment, in the two groups. MUD BMT recipients had a significantly greater incidence of grade II-IV acute GVHD (58% versus 24% in the MRD group; P = 0.02), and demonstrated a trend towards more chronic GVHD (39% versus 15%; P = 0.06). Three years post BMT, the probabilities of transplant-related mortality were 33 +/- 11% and 20 +/- 8% in MUD and MRD groups respectively (P = 0.38); the probabilities of relapse were 28 +/- 12% and 41 +/- 9% respectively (P = 0.19). Lansky or Karnofsky performance scores in event-free survivors were 90-100 in 87% of the MUD group and 83% of the MRD group. With a median follow up of 38 months (range, 3-97), 3-year event-free survival was 49 +/- 11% and 47 +/- 9% in the MUD and MRD BMT groups respectively (P = 0.71). These results suggest that MUD BMT is a valuable therapy for children with ALL in whom BMT is indicated, and underscore the importance of efforts aimed at expediting unrelated donor searches for patients lacking a MRD.
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Affiliation(s)
- F A Al-Kasim
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Fouladi M, Herman R, Rolland-Grinton M, Jones-Wallace D, Blanchette V, Calderwood S, Doyle J, Halperin D, Leaker M, Saunders EF, Zipursky A, Freedman MH. Improved survival in severe acquired aplastic anemia of childhood. Bone Marrow Transplant 2000; 26:1149-56. [PMID: 11149724 DOI: 10.1038/sj.bmt.1702699] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Multi-agent immunosuppressive therapy has produced improved survival for severe acquired aplastic anemia in children. Recently, some investigators have suggested that immunosuppressive therapy may replace bone marrow transplantation as first-line therapy for this disorder. To assess its validity, we compared the outcomes of bone marrow transplantation vs immunosuppressive therapy in one institution from 1987 to 1997. We studied 46 consecutive patients less than 18 years of age who presented between January 1987 and April 1997. Inherited marrow failure syndromes and myelodysplastic syndromes were excluded. Patients received immunosuppressive therapy vs bone marrow transplantation based on availability of HLA-matched donors. The main outcome measures were survival, complete marrow and hematological remission, or partial remission but achieving independence from transfusional support. Twenty patients received multi-agent immunosuppressive therapy (cyclosporine, antithymocyte globulin and methylprednisolone); 11 attained complete remission and three partial remission for a transfusion-independent survival of 70%. Six patients died of infectious and hemorrhagic complications. Twenty-six patients were transplanted and 24 (93%) achieved complete remission; one achieved a PR, 25 remain transfusion independent with a median follow-up of 5.9 years or 70 months. One patient developed AML 34 months after successful transplant and one patient died due to graft failure and complications of transplant. There has been a striking improvement in survival for pediatric patients treated with multi-agent immunosuppression in the last decade. However, transplantation results have also improved and this remains the definitive first-line therapy for severe acquired aplastic anemia in this age group.
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Affiliation(s)
- M Fouladi
- The Hospital for Sick Children, and Department of Pediatrics, University of Toronto Faculty of Medicine, Ontario, Canada
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19
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Abstract
This report describes and critically appraises our experience with busulfan dose adjustment in children undergoing bone marrow transplant between April 1997 and March 1999. All children received an initial busulfan dose of 40 mg/m2 p.o. or by nasogastric tube. Whole blood samples were obtained 1, 1.5 and 6 h later and analyzed for busulfan content by gas chromatography with electron capture detection. The area under the whole blood busulfan concentration vs time curve (AUC) and an individualized dose which would achieve an AUC of 1300 microM/min were calculated. Mean and median busulfan doses were calculated using actual, ideal and effective body weight and stratified according to age. The relationship between the busulfan concentration at hour 6 and AUC was determined using linear regression. Thirty-nine courses of busulfan were evaluated in 38 patients. A change from the initial busulfan dose was required to achieve the target AUC in 34 courses (87%). Most children >1 to 5 years old required dose increments while most children >5 years old required dose reductions. Obesity did not significantly affect busulfan dose requirements. Busulfan concentrations at 6 h only weakly predicted the AUC achieved (r2 = 0.496; P = 0.001). Based on these findings, we recommend that the initial busulfan dose be assigned according to patient age and actual body weight. We also recommend that busulfan AUC be calculated for children using a four-sample (1, 1.5, 4 and 6 h) limited sampling technique.
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Affiliation(s)
- L L Dupuis
- Department of Pharmacy, The Hospital For Sick Children, Toronto, Ontario, Canada
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20
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Barron MA, Duncan DS, Green GJ, Modrusan D, Connolly B, Chait P, Saunders EF, Greenberg M. Efficacy and safety of radiologically placed gastrostomy tubes in paediatric haematology/oncology patients. Med Pediatr Oncol 2000; 34:177-82. [PMID: 10696123 DOI: 10.1002/(sici)1096-911x(200003)34:3<177::aid-mpo3>3.0.co;2-g] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The treatment of malnutrition, which is of great concern in paediatric haematology/oncology patients, is fraught with problems. The goals of our study were to document the complications and assess the weight gain with gastrostomy tubes (G-tubes) in this population. PROCEDURE Patient data were acquired by retrospective review of all haematology, oncology, and bone marrow transplant (BMT) patients (n = 44) who received radiologically placed G-tubes at our institution over a 4-year period. RESULTS Forty-four G-tubes were placed (59% peri-BMT). At tube placement, 55% of patients were malnourished and 45% were nourished. Seventy-five percent of patients had the procedure without general anaesthetic. Localized G-tube-site infection was the most common complication (41%). Major complications occurred in 3 patients; 2 patients experienced localized peritonitis, and 1 patient developed a localized collection of pus in the abdominal wall. There were no G-tube-related deaths. At 1 month after the tube insertion, 39% of patients had gained, 54% maintained, and 7% lost weight. At 3 months, 69% had gained, 28% maintained, and 3% lost weight. There was a statistically significant weight gain from the time of the G-tube placement to both 1 month (P < 0.018) and 3 months (P < 0.0001) after G-tube placement. Patients in all diagnosis categories showed improvement from 1 to 3 months. CONCLUSIONS We conclude that retrograde tube placement is safe and can frequently be done without general anaesthetic and that G-tube feeding effectively reverses malnutrition and prevents weight loss in this patient population.
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Affiliation(s)
- M A Barron
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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21
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Abstract
Recent studies have demonstrated excessive telomeric shortening in peripheral blood leucocytes of bone marrow transplant (BMT) recipients. This finding has raised concerns about accelerated haemopoietic ageing that might predispose to clonal disorders and late graft failure. We studied the peripheral blood neutrophils and T cells of 14 fully engrafted long-term survivors of BMT. We found that in both neutrophils and T cells there was significant telomere shortening in the recipient (0.6 and 0.5 kb, respectively; P < 0.001 and < 0.04, respectively). We found no relationship between degree of shortening and the nucleated cell dose given at the time of transplant. We also demonstrated significantly longer telomeres in T cells than neutrophils from the same individual (mean 11.6 kb and 10.6 kb, respectively; P=0.0001). We propose mechanisms to account for these observations. The replicative stress that causes this telomere shortening does not necessarily occur at the level of the most primitive haemopoietic stem cell.
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Affiliation(s)
- R Wynn
- Department of Paediatrics, Hospital for Sick Children, Toronto, Canada
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22
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Tse S, Saunders EF, Silverman E, Vajsar J, Becker L, Meaney B. Myasthenia gravis and polymyositis as manifestations of chronic graft-versus-host-disease. Bone Marrow Transplant 1999; 23:397-9. [PMID: 10100585 DOI: 10.1038/sj.bmt.1701575] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Myasthenia gravis and polymyositis are each a rare manifestation of immune dysregulation in chronic graft-versus-host disease (cGVHD). We report a 4-year-old boy with idiopathic acquired aplastic anemia who developed myasthenia gravis 22 months and polymyositis 69 months after an allogeneic BMT (5/6 matched, MLC-nonreactive). The occurrence of both syndromes in one patient is unique. Autoimmune dysfunction may be associated with the development of cGVHD as demonstrated by the high incidence of prior aplastic anemia in BMT patients presenting with myasthenia gravis and polymyositis. Recognition of these neurologic manifestations is important in the diagnosis and treatment of cGVHD.
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Affiliation(s)
- S Tse
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
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23
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Peters C, Shapiro EG, Anderson J, Henslee-Downey PJ, Klemperer MR, Cowan MJ, Saunders EF, deAlarcon PA, Twist C, Nachman JB, Hale GA, Harris RE, Rozans MK, Kurtzberg J, Grayson GH, Williams TE, Lenarsky C, Wagner JE, Krivit W. Hurler syndrome: II. Outcome of HLA-genotypically identical sibling and HLA-haploidentical related donor bone marrow transplantation in fifty-four children. The Storage Disease Collaborative Study Group. Blood 1998; 91:2601-8. [PMID: 9516162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Untreated patients with Hurler syndrome (MPSIH) experience progressive neurologic deterioration and early death. Allogeneic bone marrow transplantation (BMT) ameliorates or halts this course. The Storage Disease Collaborative Study Group was formed to evaluate the effectiveness and toxicity of BMT. Effectiveness was defined as engrafted survival with continuing cognitive development. Fifty-four patients deficient in leukocyte alpha-L-iduronidase enzyme activity (median age, 1.8 years; range, 0.4 to 7.9) received high-dose chemotherapy with or without irradiation and BMT from HLA-genotypically identical sibling (GIS) or HLA-haploidentical related (HIR) donors between September 16, 1983 and July 14, 1995; all children were included in this report. Thirty-nine of 54 patients (72%) engrafted following the first BMT. The probability of grade II to IV acute graft-versus-host disease (GVHD) at 100 days was 32% for GIS and 55% for HIR patients. The probability of extensive chronic GVHD was 0% for GIS and 24% for HIR patients. The actuarial probability of survival at 5 years was 64% for all patients, 75% for GIS patients, 53% for HIR patients, and 53% for patients with donor marrow engraftment. The baseline Mental Developmental Index (MDI) was examined both for children less than and greater than 24 months of age at BMT. Children transplanted before 24 months had a mean baseline MDI of 78, while those transplanted after 24 months had a mean baseline MDI of 63 (P = . 0002). Both baseline and post-BMT neuropsychologic data were available for 26 of 30 engrafted survivors. Of 14 patients transplanted before 24 months of age, nine demonstrated developmental trajectories that were normal or somewhat slower than normal. In contrast, of 12 patients transplanted after 24 months of age, only three showed developmental trajectories that were normal or somewhat slower than normal (P = .01). For children with a baseline MDI greater than 70, there was a significant correlation between the MDI at follow-up study and leukocyte alpha-L-iduronidase enzyme activity (P = .02). Children were more likely to maintain normal cognitive development if they were fully engrafted following BMT from a donor with homozygous normal leukocyte alpha-L-iduronidase enzyme activity. Children who developed acute GVHD of grade II or worse had significantly poorer cognitive outcomes (P < .009). No difference in the post-BMT MDI was observed between patients whose preparative therapies did (n = 10; radiation dose, 300 to 1,400 cGy) or did not (n = 16) include radiation. We conclude that MPSIH patients, particularly those less than 24 months of age with a baseline MDI greater than 70, can achieve a favorable long-term outcome with continuing cognitive development and prolonged survival after successful BMT from a related donor with homozygous normal enzyme activity.
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Affiliation(s)
- C Peters
- Department of Pediatrics, Division of Bone Marrow Transplant, University of Minnesota, Minneapolis 55455, USA
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24
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Abstract
The calcium antagonist amlodipine may have the potential for expanded use in children owing to its physiochemistry and pharmacokinetic profile that facilitates once-daily dosing in a liquid formulation. Its safety and efficacy have not been previously evaluated in children. A retrospective analysis of 15 pediatric bone marrow transplant patients who had amlodipine incorporated into their antihypertensive drug regimen reveals significantly lower blood pressure as compared with baseline therapy (123.5+/-2.1 mmHg and 117.2+/-2.2 mmHg, systolic blood pressure before and during amlodipine, P<0.05; 81.5+/-1.8 mmHg and 75.5+/-2.6 mmHg, diastolic blood pressure before and during amlodipine, P<0.05). Amlodipine provided improved blood pressure control in this cohort and may provide a valuable pharmacologic alternative for treatment of pediatric hypertension.
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Affiliation(s)
- S Khattak
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, The University of Toronto, Ontario, Canada
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25
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Abstract
We report the results of a near total myeloablation in preparation for bone marrow transplantation in a boy with minimal symptoms of X-linked adrenoleukodystrophy. Severe cerebral X-linked adrenoleukodystrophy developed in the patient after failure of bone marrow transplantation. This experience suggests that immunotherapy alone is not responsible for the improvement observed in some patients with X-ALD after BMT.
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Affiliation(s)
- M J Nowaczyk
- Department of Pediatrics, Hospital for Sick Children, Ontario, Canada
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26
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Chattergoon DS, Saunders EF, Klein J, Calderwood S, Doyle J, Freedman MH, Koren G. An improved limited sampling method for individualised busulphan dosing in bone marrow transplantation in children. Bone Marrow Transplant 1997; 20:347-54. [PMID: 9339748 DOI: 10.1038/sj.bmt.1700891] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Busulphan (BU) pharmacokinetic (PK) studies in children undergoing bone marrow transplantation suggest that individual BU dosing may be necessary to optimise BU systemic exposure. Optimising BU systemic exposure may improve outcome and decrease toxicity in BMT. Because of practical limitations in obtaining blood from children and for financial reasons, a limited sampling method (LSM) is needed. However, such methods for BU have not been validated in children. In the present study, we individualized oral BU dosing in 10 children to target an area under the curve of BU (BU AUC) of 900-1400 microM/min based on BU AUC(0-infinity) calculated from nine serum BU concentrations performed after a BU test dose of 40 mg/m2. We validated a LSM using 3 BU concentrations to determine AUC. Six of nine patients studied (one patient non-evaluable), required their doses modified (3, lower; 3, higher). The mean percent dose change was 26.2% (range -33.3% to +45.3%). Our three sample LSM BU AUC(0-infinity) (1098 +/- 344, mean +/- 1 s.d.) correlated highly with our nine sample BU AUC(0-infinity) (1132 +/- 389, Pearson r = 0.98, P = 0.0001) and was not significantly different by t-test (P = 0.3). The mean percentage difference between the three sample LSM AUCs and the nine sample AUCs in each of our patients was 7.5%, (range -10.99% to +9.4%). Trough levels correlated extremely well with AUC (r = 0.95, P = 0.0001). Individual BU dosing, based on AUC, is necessary in most children to achieve targeted levels of BU therapy. An LSM of three BU concentrations performed at 0.5 h, 1 h and 6 h post-BU test dose closely predicts the AUC calculated from nine sampling points.
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Affiliation(s)
- D S Chattergoon
- Division of Hematology/Oncology, Hospital for Sick Children, and University of Toronto, Ontario, Canada
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27
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Calderwood S, Doyle JJ, Hitzler JK, Saunders EF, Freedman MH. Administration of recombinant human granulocyte-macrophage colony-stimulating factor after autologous bone marrow transplantation in children with acute myelogenous leukemia: a note of caution. Bone Marrow Transplant 1996; 18:87-91. [PMID: 8832000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A series of 22 consecutive pediatric patients undergoing ABMT for treatment of primary AML was reviewed in an efficacy analysis of recombinant human granulocytemacrophage colony-stimulating factor (rhGM-CSF). Treatment with at least two cycles of chemotherapy and a standard conditioning regimen of busulfan and cyclophosphamide preceded the marrow infusion. Twelve patients who underwent transplants between 1992 and 1994 received 5.5 micrograms/kg/day rhGM-CSF as part of their transplant protocol. They were compared with 10 patients who underwent transplants between 1989 and 1991 but did not receive rhGM-CSF. Despite containing a significantly higher proportion of patients in first clinical remission at the time of the transplant, the rhGM-CSF-treated group had a significantly higher relapse and poorer overall survival rate after ABMT than the untreated group (36 vs 90%). The rhGM-CSF-treated group tended to have more rapid neutrophil engraftment and shorter hospital stays; however, neither of these trends was statistically significant. To properly determine the role of rhGM-CSF in the survival of pediatric patients undergoing ABMT for treatment of AML, a prospective randomized trial is desirable. Until these data are available, the current analysis suggests that particular caution is indicated with the use of this drug in this group of patients.
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Affiliation(s)
- S Calderwood
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
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28
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King SM, Saunders EF, Petric M, Gold R. Response to measles, mumps and rubella vaccine in paediatric bone marrow transplant recipients. Bone Marrow Transplant 1996; 17:633-6. [PMID: 8722367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Bone marrow transplant (BMT) recipients are routinely reimmmunized with the childhood vaccine series after transplantation excluding the live attenuated vaccines. In this study, the clinical and serologic responses to measles, mumps and rubella (MMR) vaccine in children after BMT was assessed. Twenty-two BMT recipients were vaccinated with MMR II (MSD). All were at least 2 years post-BMT and without GVHD. Their underlying conditions were leukemia (11), aplastic or Fanconi's anemia (7), thalassemia (3) and metabolic disease (1). All were allogeneic transplants with matched related donors. The mean age at transplantation was 6.9 years. There were no reported adverse effects of the vaccination. Antibody status for MMR was determined using commercial assays (IFA and ELISA) on paired specimens. The mean interval between transplantation and vaccination was 48 months. Pre-vaccination, no BMT recipient was sero-positive for all three, but 23% were positive for measles, 31% for mumps and 14% for rubella. Post-vaccination, 68% of BMT recipients were sero-positive for all three, with 77% for measles, 87% for mumps and 91% for rubella. Therefore, MMR vaccination at 2 years or later after BMT in paediatric recipients without GVHD was safe and significantly increased the proportion sero-positive for MMR.
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Affiliation(s)
- S M King
- Division of Infectious Diseases, Hospital for Sick Children, Ontario, Canada
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29
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Berkovitch M, Matsui D, Zipursky A, Blanchette VS, Verjee Z, Giesbrecht E, Saunders EF, Evans WE, Koren G. Hepatotoxicity of 6-mercaptopurine in childhood acute lymphocytic leukemia: pharmacokinetic characteristics. Med Pediatr Oncol 1996; 26:85-9. [PMID: 8531858 DOI: 10.1002/(sici)1096-911x(199602)26:2<85::aid-mpo3>3.0.co;2-q] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Treatment with 6-mercaptopurine (6MP) is associated with adverse gastrointestinal (GI) and hepatic effects. Four patients, ages 6.9 +/- 2.6 (mean +/- S.D.) years, with acute lymphocytic leukemia (ALL) on maintenance chemotherapy including 6MP, developed nausea, vomiting, abdominal pain, elevated liver enzymes, and hyperbilirubinemia after 1.4 +/- 1.0 (range 0.5-2) years. Liver biopsy in 1 patient was suggestive of drug-induced intrahepatic cholestatis. Symptoms resolved and liver function returned to normal after discontinuation of 6MP. Pharmacokinetic data of the symptomatic patients were compared with those of 25 ALL patients on the same protocol but without GI symptoms or hepatotoxicity. Levels of 6-thioguanine nucleotides (6-TGN) and the methylated metabolites of 6MP in red blood cells of the patients with hepatotoxicity, were not significantly different when compared to patients without hepatotoxicity, suggesting similar absorption of 6MP in both groups. Time to achieve peak 6MP levels was significantly longer in the symptomatic patients compared to the asymptomatic patients (P = 0.005). Peak levels and standardized concentration versus time curve (AUC) per 1 mg of 6MP per m2 of body surface area were significantly lower in the patients with hepatotoxicity (P = 0.016; P = 0.037, respectively). A significant correlation between peak 6MP levels and standardized AUC (r = 0.729, P < 0.0001) was found. These results suggest accumulation of 6MP and its metabolites in the liver of the patients with GI symptoms, leading to hepatotoxicity.
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Affiliation(s)
- M Berkovitch
- Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, Toronto, Canada
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30
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Freedman MH, Cohen A, Grunberger T, Bunin N, Luddy RE, Saunders EF, Shahidi N, Lau A, Estrov Z. Central role of tumour necrosis factor, GM-CSF, and interleukin 1 in the pathogenesis of juvenile chronic myelogenous leukaemia. Br J Haematol 1992; 80:40-8. [PMID: 1311195 DOI: 10.1111/j.1365-2141.1992.tb06398.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
In previous studies on patients with juvenile chronic myelogenous leukaemia (JCML), we found excessive proliferation of malignant monocyte-macrophage elements in the absence of exogenous growth factor, and impaired growth of normal haematopoietic progenitors. In the current study, six newly-diagnosed JCML patients were investigated to characterize the disease further. In co-cultures, JCML cell culture supernatant as well as patient plasma obtained at diagnosis produced a striking reduction in numbers of control marrow BFU-E, CFU-GM, CFU-Meg and CFU-GEMM colonies. Monoclonal anti-tumour necrosis factor alpha neutralizing antibodies (anti-TNF-alpha Ab) abolished these inhibitory properties. In sharp contrast, JCML supernatants exerted a marked growth-promoting effect on autologous JCML cells cultured in clonogenic assays. Anti-TNF-alpha Ab and anti-granulocyte-macrophage colony-stimulating factor neutralizing antibodies (anti-GM-CSF Ab) both reversed the stimulating effect. Recombinant GM-CSF and recombinant TNF alpha produced a profound increase in JCML colonies when tested individually and anti-GM-CSF Ab reversed the TNF-alpha effect. Expression studies of TNF-alpha and TNF-alpha receptor genes of cultured JCML cells demonstrated mRNAs for both. Further, TNF-alpha activity was assayed in a wide variety of cell culture supernatants and in normal and patients' plasma, and only the JCML specimens showed increased TNF-alpha values. Recombinant interleukin-1 alpha (IL-1 alpha) also stimulated JCML colony growth, but polyclonal anti-IL-1 neutralizing antibodies did not suppress JCML colony numbers nor did it reverse the effects of TNF-alpha or GM-CSF. The evidence indicated that the JCML monokine which inhibits normal haematopoiesis is TNF-alpha and that the endogenously-produced TNF-alpha and GM-CSF from JCML cells play an important role in the pathogenesis of the disease by acting as autocrine growth factors. IL-1 alpha also stimulates JCML cell proliferation as an accessory factor and augments the effect of GM-CSF, TNF-alpha or both.
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MESH Headings
- Base Sequence
- Bone Marrow/immunology
- Child
- Child, Preschool
- Colony-Forming Units Assay
- Female
- Granulocyte-Macrophage Colony-Stimulating Factor/immunology
- Hematopoiesis/immunology
- Humans
- Infant
- Interleukin-1/immunology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/immunology
- Male
- Molecular Sequence Data
- Receptors, Cell Surface/genetics
- Receptors, Tumor Necrosis Factor
- Recombinant Proteins/immunology
- Tumor Cells, Cultured/immunology
- Tumor Necrosis Factor-alpha/immunology
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Affiliation(s)
- M H Freedman
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
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31
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Feig SA, Krailo MD, Harris RE, Baum E, Holcenberg JS, Kaizer H, Steinherz L, Pendergrass TW, Saunders EF, Warkentin PL. Determination of the maximum tolerated dose of idarubicin when used in a combination chemotherapy program of reinduction of childhood ALL at first marrow relapse and a preliminary assessment of toxicity compared to that of daunorubicin: a report from the Childrens Cancer Study Group. Med Pediatr Oncol 1992; 20:124-9. [PMID: 1734217 DOI: 10.1002/mpo.2950200207] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
An escalating-dose trial of idarubicin, used weekly for 3 doses in combination with vincristine, prednisone, and L-asparaginase (VPLI), to reinduce remission of childhood ALL at first bone marrow relapse was conducted by the Childrens Cancer Study Group (CCSG). The maximum tolerated dose (MTD) of idarubicin, used in the manner, was determined to be 12.5 mg/m2/dose. Twelve of 16 (75%) evaluable patients in first marrow relapse of ALL treated at a dose of 10 or 12.5 mg/m2 entered a second complete remission, compared to 41 of 69 evaluable patients (59%) treated in a comparable way with daunorubicin (30 mg/m2) (VPLD). Prolonged myelosuppression was observed in both groups, but the frequency of documented bacterial sepsis and the duration of required hospitalization were greater among patients treated with idarubicin. No additional toxicity, specifically attributable to idarubicin, was observed at these doses.
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Affiliation(s)
- S A Feig
- University of California School of Medicine, Los Angeles
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32
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Abstract
The current working hypothesis on the pathogenesis of autoimmune disease focuses on the interactions between susceptibility genes and environmental stimuli. In Graves' disease it is postulated that aberrant expression of HLA class II antigens on thyroid epithelial cells permits the presentation of specific thyroid antigen to activated lymphocytes. Evidence suggests that thyrocyte HLA-DR expression is secondary to the production of cytokines by presensitized T-lymphocytes. A 20-yr-old woman and her 18-yr-old brother presented with classical findings of Graves' disease with ophthalmopathy within a year of each other. Diagnosis was confirmed by demonstration of elevated serum levels of T4 and T3, strongly positive titers of TSH binding inhibitory immunoglobulins, and histological examination after subtotal thyroidectomy. Eight years previously, acute life-threatening aplastic anemia in the brother led to therapeutic transplantation of bone marrow from his sister. After the procedure, 100% of his peripheral leucocytes were genotype 46,XX. HLA typing performed before transplantation and 2 months after thyroidectomy in the female indicated complete identity with her brother's leukocytes for class I and class II antigens. Thyroid autoantibodies at this time were weakly positive. Although the concordance of thyroid disease in these patients could be due to chance, the patients were of different sexes, the family history was negative, and neither the probands nor the first degree relatives bore the HLA-DR3/B8 antigens. We propose that the male passively acquired a clone of programmed or activated lymphocytes from his sister and that his hyperthyroidism was not primarily dependent on exposure to specific thyroid-derived antigen.
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Affiliation(s)
- F J Holland
- Department of Pediatrics, University of Toronto, Ontario, Canada
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33
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Abstract
Drug-induced aplastic anemia is one of the few life-threatening reactions to drugs. Although the majority of reported cases have been associated with chloramphenicol, many drugs have the potential to be toxic to the bone marrow. There are two distinct types of toxicity with differing pathogenic mechanisms--a dose-related reversible marrow aplasia and a dose-independent idiosyncratic aplasia with a high mortality. These two forms of marrow suppression may be difficult to distinguish. The pathogenesis of idiosyncratic marrow aplasia is not well understood. Various studies have demonstrated biochemical, immune, pharmacokinetic, and genetic defects that could affect hematopoietic stem cells. The clinical significance of the reported experimental findings is not established. The prognosis of drug-induced aplastic anemia is similar to that of idiopathic aplastic anemia. Patients with this condition respond to bone marrow transplantation or immunosuppressive therapy in a manner similar to patients with idiopathic marrow aplasia. Many questions regarding drug-induced aplastic anemia remain to be answered; little progress has been made in the last decade.
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Affiliation(s)
- D Malkin
- Division of Hematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
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34
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Leson CL, Bryson SM, Giesbrecht EE, Saunders EF. Therapeutic monitoring of cyclosporine following pediatric bone marrow transplantation: problems with sampling from silicone central venous lines. DICP 1989; 23:300-3. [PMID: 2658375 DOI: 10.1177/106002808902300405] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Blood concentrations are commonly used to guide dosing requirements of cyclosporine, due to large variations in pharmacokinetics both between and within individuals. Bone marrow transplant patients at The Hospital for Sick Children are prescribed intravenous cyclosporine as part of the posttransplant immunosuppression protocol. Sampling for blood concentration measurement is generally done via a single-lumen central venous line (CVL). Cyclosporine concentrations sampled by this route were compared with concentrations in peripheral capillary samples taken concurrently. Results from the CVL blood were substantially higher despite appropriate flushing of the CVL between the end of the infusion and the time of sample collection. This discrepancy disappeared once the patient was converted to oral cyclosporine. We conclude that the sampling error is due to drug adsorbed to the silicone CVL catheters during intravenous administration and displaced during blood sample collection.
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Affiliation(s)
- C L Leson
- Department of Pharmacy, Hospital for Sick Children, Toronto, Ontario, Canada
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Abstract
Improved survival in childhood acute lymphoblastic leukemia has led to the occurrence of second malignancies in these patients. Hodgkin's disease is very rare as a second malignancy. We report three patients with acute lymphoblastic leukemia in remission who developed Hodgkin's disease. Although all had received low-dose irradiation, none received alkylating agents as part of their chemotherapy. Review of our cases and of 11 reported in the literature revealed unique aspects of this association. There was a short median interval of 19 months to the development of the second malignancy. Over one-third of the patients had uncommon sites of involvement (lung, tonsil, small bowel). The distribution of histologic subtypes was unusual, as 5 of 14 cases had lymphocyte depletion or unclassifiable Hodgkin's disease. The results of therapy were excellent. Our three patients are alive, with both malignancies in continuing remission. Two patients are off all therapy for 4 and 6 years, respectively. The third remains on antileukemic treatment. Secondary Hodgkin's disease in childhood acute lymphoblastic leukemia does not appear to have a poor prognosis and long-term survival and possible cure of both diseases may be achieved.
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Abstract
The mechanism of anemia in four patients with transient red cell aplasia of childhood ("erythroblastopenia") was studied at the time of diagnosis by assessing the colony growth of marrow erythroid progenitors in methylcellulose tissue cultures. Marrow from Patient 1 yielded high normal numbers of BFU-E colonies that were completely abolished on addition of autologous serum or IgG. Patient 2 had normal BFU-E growth that markedly declined when autologous serum or IgM was added to the cultures, but growth remained unchanged with added autologous IgG or peripheral blood mononuclear cells (PBMC). Marrow from Patient 3 yielded low CFU-E and BFU-E numbers with standard plating techniques, but colonies strikingly increased when marrow fractions from an albumin density gradient were cultured. PBMC from Patient 3 suppressed control marrow CFU-E and BFU-E, but serum had no effect. Patient 4 had normal CFU-E and BFU-E that increased with autologous serum and remained unchanged with autologous PBMC. We conclude that the red cell aplasia in Patients 1, 2, and 3 was due to suppressed erythropoiesis via IgG, IgM, and cell-mediated inhibition, respectively. In contrast, in Patient 4 no immune mechanism was demonstrated. Whereas transient red cell aplasia has a uniform clinical presentation, there are at least four pathogenetic mechanisms that can be detected in vitro.
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Abstract
The anemia of chronic renal failure was studied by assessing the effect of uremic serum on proliferation of human marrow erythroid stem cells into colonies in vitro. Of 50 sera tested, 46 inhibited "CFU-E" colony formation by a mean of 72%, and 42 inhibited "BFU-E" colonies by a mean of 53.5%, compared to normal sera. Analysis of the uremic sera revealed a striking increase of ribonuclease activity in every patient. Mean activity in the study group was 17,346 U/ml serum (range 6,700-36,250) compared to control mean of 1,047 +/- 247 U/ml. Purified ribonuclease added to marrow cultures in concentrations simulating uremic serum produced a dose-dependent decrease in CFU-E colonies suggesting that the substance has a role in the production of anemia of renal failure.
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38
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Abstract
The pathogenesis of anemia in patients with end-stage renal disease was studied by assessing the effect of uremic serum on the proliferation and maturation of erythroid progenitor cells, BFU-E and CFU-E, into colonies in vitro. Nucleated peripheral blood cells from 10 anemic patients produced normal or increased numbers of BFU-E colonies in response to added erythropoietin when cultured in control serum, but declined a mean of 63% when autologous uremic serum was substituted. Uremic sera from 90 patients cultured with normal human marrow produced a mean decrease in BFU-E colony growth of 72%, and of CFU-E colony growth of 82%, compared to control serum. Neither hemodialysis nor peritoneal dialysis was effective in removing the inhibitor. We conclude that patients with uremia have adequate circulating erythroid progenitors that respond to erythropoietin normally when removed from the uremic environment, and that uremic serum is toxic and inhibitory to erythropoiesis. This may be an important mechanism in the anemia of chronic renal failure.
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Abstract
To study the action of corticosteroids on erythroid precursors, (burst forming unit-erythroid and colony forming unit-erythroid) in Diamond-Blackfan Syndrome (DBS), marrow from a newly diagnosed untreated infant was studied in vitro with prednisone and dexamethasone. This patient subsequently proved to be steroid responsive. Colony numbers increased linearly in an erythropoietin (EPO) dose response study. There was marked enhancement of colony numbers at all EPO doses after adding either prednisone (10(-6) M) or dexamethasone (10(-9) M) to the cultures. The data indicate that corticosteroids augment erythropoiesis at both early (BFU-E) and late (CFU-E) stages of development in DBS. In contrast, marrow from a second infant with DBS, clinically steroid resistant, failed to respond to steroids in vitro.
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40
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Abstract
We studied the in vitro proliferative characteristics of marrow erythroid progenitors, colony forming unit-erythroid (CFU-E) and burst forming unit-erythroid (BFU-E), in two infants with Diamond-Blackfan syndrome before and during prednisone treatment. Patient 1, had a brisk erythropoietic response to prednisone and the anemia improved; Patient 2 was steroid-unresponsive. Marrow from Patient 1 yielded linear increases in numbers of colonies in erythropoietin dose-response studies, and the magnitude of response was much greater while on prednisone compared to pretreatment. Cultures of stem cell rich fractions of marrow from Patient 1 separated by unit gravity sedimentation (STA-PUT) revealed moderately reduced CFU-E and BFU-E numbers before prednisone, but normal colony numbers during treatment. Patient 2 differed because CFU-E and BFU-E were almost absent at all erythropoietin doses before and during therapy. Even stem cell rich marrow fraction initially yielded very low colony numbers which did not increase significantly while on prednisone. These findings suggest that in Patient 1 there were adequate numbers of progenitors that were able to differentiate normally only in the presence of prednisone. In Patient 2 the erythropoietic failure in vivo and in vitro was unaffected by prednisone.
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41
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Abstract
To assess the capacity of the human spleen to function as a hematopoietic organ, spleen mononuclear cells from patients undergoing splenectomy were cultured to assay CFU-E, BFU-E, and CFU-C. Although the peripheral blood from cases of hereditary spherocytosis, Gaucher disease, Thalassemia major, and idiopathic thrombocytopenic purpura yielded 3-20 BFU-E/5 X 10(5) cells plated and 1-7 CFU-C/5 X 10(5), suspensions of spleen cells failed to grow colonies. Histologically these spleens did not show extramedullary hematopoiesis. In contrast, peripheral blood from a patient with osteopetrosis (marble bone disease) yielded 130 BFU-E/5 X 10(5), 40 CFU-E/5 X 10(5), and 9 CFU-C/5 X 10(5). The spleen had extensive extramedullary hematopoiesis on microscopy and grew 180 BFU-E/10(5), 210 CFU-E/10(5), and 25 CFU-C/10(5). We conclude that spleens from patients without extramedullary hematopoiesis do not contain committed hematopoietic progenitors in spite of normal precursors in the blood. In osteopetrosis the spleen contained stem cells in a concentration comparable to bone marrow, and the embryonic role of the spleen in blood formation appeared to continue in postnatal life.
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Abstract
We treated five children with chronic neutropenia using lithium carbonate and studied the effect in vivo on granulopoiesis. Granulocyte precursors (CFU-C) from blood and marrow, and colony-stimulating activity (CSA) from peripheral blood leukocytes, were assayed in a methylcellulose tissue culture system. Three patterns of response to lithium were seen. In patients with aplastic anemia (one acquired and two Fanconi's aplastic anemia) despite increased colony-stimulating activity, CFU-C numbers remained very low and the neutropenia persisted. In a patient with Kostmann neutropenia colony-stimulating activity, and blood and marrow CFU-C numbers increased, but the agranulocytosis was unchanged. An impressive therapeutic effect was seen in one patient with idiopathic neutropenia with low colony-stimulating activity who responded to lithium with an increase in colony-stimulating activity and CFU-C resulting in persisting normal neutrophil counts. Lithium appears useful in treating a select group of neutropenic patients in whom colony-stimulating activity production is responsive to lithium, and the granulocytic progenitor compartment is capable of producing mature neutrophils.
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Freedman MH, McDonald TP, Saunders EF. Differentiation of murine marrow megakaryocyte progenitors (CFUm): humoral control in vitro. Cell Tissue Kinet 1981; 14:53-8. [PMID: 7471155 DOI: 10.1111/j.1365-2184.1981.tb00510.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Differentiation of mouse marrow megakaryocyte progenitors (CFUm) was studied in vitro by a colony assay using a plasma clot system. Erythropoietin (EPO) from sheep plasma (6 units/mg protein) in doses from 1 to 5 units/ml induced a linear increase in CFUm to a maximum of 20 colonies/10(5) cells plated. Human urinary EPO also induced a dose-responsive increase in CFUm, but the maximum was 9 colonies/10(5) with 2.0 units/ml of EPO and there was a decrease in colonies above that concentration. Thrombocytopoiesis-stimulating factor (TSF) derived from human embryonic kidney culture supernatant fluids induced a dose-responsive increase in CFUm in concentrations from 0.01 to 0.32 mg protein/ml in the absence of added EPO. TSF did not support the growth in vitro of erythroid colonies from mouse marrow (CFUe and BFUe) indicating the absence of EPO activity. In these studies sheep EPO appeared more effective in supporting CFUe growth than human EPO. TSF also had a stimulatory function in megakaryocyte differentiation at a precursor level. Multiple humoral factors play a role in megakaryocytopoiesis in vitro.
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Chan HS, Freedman MH, Saunders EF. Stimulation of granulopoiesis in vitro and in vivo using lithium in children with chronic neutropenia. Adv Exp Med Biol 1980; 127:293-304. [PMID: 6967681 DOI: 10.1007/978-1-4757-0259-0_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Chan HS, Saunders EF, Freedman MH. Modulation of human hematopoiesis by prostaglandins and lithium. J Lab Clin Med 1980; 95:125-32. [PMID: 6243155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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46
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Saunders EF, Gall G, Freedman MH. Granulopoiesis in Shwachman's syndrome (pancreatic insufficiency and bone marrow dysfunction). Pediatrics 1979; 64:515-9. [PMID: 315048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Granulopoiesis was studied in 10 children with Shwachman's syndrome (chronic neutropenia and exocrine pancreatic insufficiency). Marrow proliferative activity assessed by determination of mitotic indices and tritiated thymidine uptake into granulocytic cells was normal. Assay of bone marrow granulocyte colony-forming cells (CFU-C) in a methylcellulose tissue culture system demonstrated normal CFU-C numbers in four patients and reduced numbers in five. The granulocyte colonies formed were indistinguishable from normal colonies morphologically. Production of colony-stimulating activity (CSA) from patients' peripheral blood leukocytes appeared normal when tested on control marrow. No serum inhibitors against CFU-C or CSA could be demonstrated using both control and autologous marrow, and co-culture of patients' peripheral blood lymphocytes with control marrow did not inhibit CFU-C growth. We conclude that in Shwachman's syndrome committed granulocytic stem cells are present, and the numbers detected in vitro vary widely as does the clinical neutropenia. The proliferative activity of recognizable granulocytic cells is normal and neither a deficiency of humoral stimulators nor the presence of serum or cellular inhibitors of granulopoiesis can be demonstrated.
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47
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48
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Heddle JA, Lue CB, Saunders EF, Benz RD. Sensitivity to five mutagens in Fanconi's anemia as measured by the micronucleus method. Cancer Res 1978; 38:2983-8. [PMID: 679206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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50
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Freedman MH, Saunders EF. Diamond-Blackfan syndrome: evidence against cell-mediated erythropoietic suppression. Blood 1978; 51:1125-8. [PMID: 647116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The profound anemia of Diamond-Blackfan syndrome (DBS) is due to marrow red cell failure, but the pathogenesis is not understood. Studies by others indicated cell-mediated erythropoietic suppression in this condition. To explore this mechanism further, Ficoll-Hypaque--separated peripheral blood lymphocytes (PBL) from four anemic untreated patients with DBS, or from normals were cocultured with control marrow in vitro and the growth of erythropoietin-responsive stem cell colonies (CFU-E) was dermined. CFU-E numbers obtained from cultures with added normal PBL were not significantly different from the number without PBL. Similarly, CFU-E from cultures with added DBS PBL were not significantly different from the number without PBL (215 versus 220, 229 versus 220 and 84 versus 60, 74 versus 94/10(5) cells, respectively). Mixing marrows from a control and one DBS patient in ratios of 2:1, 1:1, or 1:2 prior to culture failed to disclose a decrease of colony growth. We could not show cellular inhibition of erythropoiesis in these patients with DBS. The mechanism of anemia in this disorder remains an open question.
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