Fractionated Radiosurgery in Large Volume Relapsed Glioblastoma Multiforme

PURPOSE/OBJECTIVE(S)

Relapse is part of the natural history in glioblastoma (GBM) and there are limited advances in surgical, alternating electric field therapy (TTF), chemotherapy (CTX), immunotherapy or radiotherapeutic treatments. Radiosurgery (SRS) and Fractionated Stereotactic Radiosurgery (FSRS) may be an option, but remains controversial. We performed a review of our patients with recurrent large volume glioblastoma treated with FSRS over the last 5 years.

MATERIALS/METHODS

Since January 2017 to December 2021, we reviewed our experience with large volume FSRS for the treatment of selected patients with large volume GBM recurrence. Indications and treatment planning were done according RANO criteria MR images. Overall survival (OS) and progression-free survival (PFS) after salvage FSRS were the primary endpoints evaluated. Response to FSRS was assessed with clinical evaluation and using brain MR.

RESULTS

A total of 15 patients with GBM recurrence were treated in our institution after surgery plus adjuvant radio-chemotherapy treatment with Stupp regimen. Median age was 58 (53-74) years old. Prescription dose was 24 Gy in 4 fractions in consecutive days. Selected patients for FSRS had a good PS with large volume relapse and edema. The target volume (CTV) was the enhanced volume in MR T2 classically known has edema and the relapsed T1 volume with gadolinium uptake. The median PTV was 118.5 cc (50-244cc). 33% of the patients received concurrent chemotherapy or biological therapy with or after FSRS. No patient developed G3 symptomatic adverse radiation effect. Median follow-up was 28.6 (10-82) months from diagnosis. PFS after salvage FSRS was 11 (4-55) months. Median overall survival was 12.4 months after FSRS.

CONCLUSION

Our experience and results suggest that reirradiation provides encouraging disease control and survival rates in GBM relapsed patients. The large volume FSRS associated or not with systemic treatment had good tolerance and can improve survival of patients with relapsed large volume GBM. Randomized controlled trials are needed to establish the optimal management strategy for recurrent GBM.

Model-based operational guidelines of a bioprocess for biological nitrogen removal and complete stabilisation of anaerobically digested sewage sludge

The concept of one-stage reactor system for biological nitrogen removal over nitrite of ammonium high loaded sidestreams is going to be applied to remove nitrogen from anaerobically digested sewage sludge and to achieve its complete stabilisation. Dealing with sludge, the organic matter needed to denitrify is present in the inflow as particulate substrate, which requires a hydrolysis step. The latter implies high anoxic hydraulic retention time (HRT). During both aerobic and anoxic phases, ammonium is released which implies the need to enlarge aerobic HRT. Both effects lead to a total HRT higher than those for nitrification-denitrification of wastewater with soluble substrate. The purpose of this paper is to define, by computer simulation, a set of theoretical criteria, which will be applied later to the operation of a pilot-scale post-aeration reactor to be located in a Spanish WWTP. These criteria will be defined by simulating the reactor performance under different operating conditions. As a conclusion, some operation guidelines have been established for the above-mentioned scenario in terms of aerobic and anoxic retention time, dissolved oxygen concentration and effluent requirements (NH(4)(+), NO(2)(-) and NO(3)(-)).

Validating the colloid model to optimise the design and operation of both moving-bed biofilm reactor and integrated fixed-film activated sludge systems

The paper presents a systematic study of simulations, using a previously calibrated Colloid model, from which it was found that: (i) for pure moving-bed biofilm reactor (MBBR) processes with tertiary nitrification conditions (no influent chemical oxygen demand (COD)), dissolved oxygen = 5 mg/L and residual NH4-N > 4 mgN/L, a nitrification rate of 1.2 gN/(m(2)d) was obtained at 10 °C. This rate decreases sharply when residual NH4-N is lower than 2 mgN/L, (ii) for MBBR systems with predenitrification-nitrification zones and COD in the influent (soluble and particulate), the nitrification rate (0.6 gN/(m(2)d)) is half of that in tertiary nitrification due to the effect of influent colloidal XS (particulate slowly biodegradable COD) and (iii) for integrated fixed-film activated sludge (IFAS) processes the nitrification rate in the biofilm (0.72 gN/(m(2)d)) is 20% higher than for the pure MBBR due to the lower effect of influent XS since it is adsorbed onto flocs. However, it is still 40% lower than the tertiary nitrification rate. In the IFAS, the fraction of the nitrification rate in suspension ranges from 10 to 70% when the aerobic solids retention time varies from 1.4 to 6 days.

[Indications and use of prothrombin complex in cardiac surgery]

On of the most common, and serious, complications in cardiac surgery is postoperative bleeding. According to the majority of studies, between 10% and 92% of patients subjected to elective surgery require transfusions of blood products and blood derivatives. Transfusions and reinterventions are associated with longer stays in critical care units and a decrease in survival rates. There have been some important changes in the treatment of changes in haemostasis and post-surgical bleeding in the last few years, particularly with the introduction into clinical practice of working procedures backed up by clinical guidelines, as well as the appearance of new drugs. The aim of this work is to describe the main characteristics and update the use of prothrombin complexes that are currently available in Spain, with special emphasis on their use in cardiac surgery.

Extended mixed-culture biofilms (MCB) model to describe integrated fixed film/activated sludge (IFAS) process behaviour

This paper presents how, in a calibration process, different assumptions regarding the standard Mixed-Culture Biofilms (MCB) model were able to match the average results at a continuous Johannesburg pilot plant (comprising two aerobic reactors, AE1 and AE2), but failed to match the batch test results of either the rate of endogenous carbonaceous oxygen uptake (OUR) or the rate of nitrate production (NPR). Under the first assumption, where attachment and diffusion of particulate components were not used, the OUR in the biofilm of the first aerobic reactor (AE1) was too low due to the absence of slowly biodegradable COD (X(S)) attachment flux. In a second assumption, where high diffusion and attachment coefficients were used, the NPR in the biofilm of the AE1 reactor exceeded the experimental value due to the high attachment flux used for nitrifiers (X(A)) and the low competition for space from X(S) and heterotrophic bacteria (X(H)). The only way to match all the experimental results was through the use of a higher attachment coefficient for X(S) in the first reactor (AE1), but this was considered unreasonable. Hence, an extended model was developed where a colloidal state, which interacts at the same time with the flocs and the biofilm through attachment-detachment processes, is distinguished. This model allowed the experimental results to be matched, but using the same value for the attachment coefficients of all particulate components.

Standard signal processing using enriched sensor information for WWTP monitoring and control

Important indicators for monitoring and control of wastewater treatment plants (WWTP) often have to be obtained from the processing of on-line signal trajectories. Therefore, the quality of sensor instantaneous measurements can be improved significantly if they are complemented with valuable information about the geometric features of their trajectories. The present paper describes the design and implementation of a Standard Signal Processing Architecture (SSPA) from which enriched sensor information is generated automatically. The SSPA has been made up of three complementary modules: the pre-processing module, the storage module and the post-processing module. Moreover, the SSPA has been parameterised so as to allow its adaptation to the specifications of every signal. By performing basic calculations on pre-processed signal trajectories, the storage module produces enriched vectors which collect information of the first and second time derivatives, average and variance values, peak values, linear regression parameters, curvature, etc. Then, the enriched information vectors can be exploited to implement customised monitoring and control tools. In this respect, the effectiveness of the SSPA has been demonstrated in three different practical cases: (1) OUR and KLa identification algorithms; (2) processing of measurements for real-time controllers; and, (3) detection of bend-points in on-line signals of SBR processes.

PET/CT image registration: Preliminary tests for its application to clinical dosimetry in radiotherapy

The quality of dosimetry in radiotherapy treatment requires the accurate delimitation of the gross tumor volume. This can be achieved by complementing the anatomical detail provided by CT images through fusion with other imaging modalities that provide additional metabolic and physiological information. Therefore, use of multiple imaging modalities for radiotherapy treatment planning requires an accurate image registration method. This work describes tests carried out on a Discovery LS positron emission/computed tomography (PET/CT) system by General Electric Medical Systems (GEMS), for its later use to obtain images to delimit the target in radiotherapy treatment. Several phantoms have been used to verify image correlation, in combination with fiducial markers, which were used as a system of external landmarks. We analyzed the geometrical accuracy of two different fusion methods with the images obtained with these phantoms. We first studied the fusion method used by the PET/CT system by GEMS (hardware fusion) on the basis that there is satisfactory coincidence between the reconstruction centers in CT and PET systems; and secondly the fiducial fusion, a registration method, by means of least-squares fitting algorithm of a landmark points system. The study concluded with the verification of the centroid position of some phantom components in both imaging modalities. Centroids were estimated through a calculation similar to center-of-mass, weighted by the value of the CT number and the uptake intensity in PET. The mean deviations found for the hardware fusion method were: deltax/ +/-sigma = 3.3 mm +/- 1.0 mm and /deltax/ +/-sigma = 3.6 mm +/- 1.0 mm. These values were substantially improved upon applying fiducial fusion based on external landmark points: /deltax/ +/-sigma = 0.7 mm +/- 0.8 mm and /deltax/ +/-sigma = 0.3 mm 1.7 mm. We also noted that differences found for each of the fusion methods were similar for both the axial and helical CT image acquisition protocols.

Design and operation of SBR processes for small plants based on simulations

The paper firstly presents an experimental study in a SBR pilot plant operated at 20 degrees C for nitrogen removal from a very small village wastewater. The plant consisted of only one reactor fed continuously throughout the day and aerated intermittently. Two tests with seven and three intermittences of mixing/aerated phases were conducted and verification of the results by simulations of the activated sludge model (ASM) was also carried out. The experimental results and simulation showed that a wide range of effluent N03-N can be obtained using different numbers of intermittences and values of the oxygen transfer coefficient (K(L)a). At the same time, the paper presents a design procedure for SBR processes based on an iterative process of simulations of the ASM model. After the selection of the cycle time, the mixing/aeration pattern, the initial volume, the solid retention time, and the duration of the phases, the simulation is undertaken, resulting in values for the effluent NH4-N and NO3-N, and the suspended solids before settling. Then, the latter parameters are verified to match the effluent and settling requirements. As an application of the design procedure, the effect on design and operation of different SBR configurations and of several operating conditions are analysed in three case studies.

Optimizing and modelling nitrogen removal in a new configuration of the moving-bed biofilm reactor process

A new configuration of the moving-bed biofilm reactor process with pre-denitrification and nitrification was investigated in a pilot plant, which is fed with urban raw wastewater, the primary settler is located between the anoxic and the aerobic reactors, and primary sludge is recycled to the anoxic reactor as a hybrid pre-denitrification. The carriers used in the experiments are made of high-density polyethylene, with a diameter of 10 mm and a specific surface area of 400 m(2)/m(3). The new process was compared with conventional pre-denitrification-nitrification using in-series reactors fed with settled wastewater. The new configuration achieved an increase of 45% for the denitrification rate and of 30% for the nitrification rate when compared with conventional configuration. These results were analysed in light of the calibration study of the mixed-culture biofilm (MCB) model and simulations in AQUASIM 2.1 platform. Regarding denitrification, the high values obtained in the new configuration were attributed to a higher removal of the slowly biodegradable substrate (Xs) in the anoxic reactor due to the use of raw wastewater and sludge recycle. Accordingly, the amounts of heterotrophic biomass (XH) and Xs obtained in simulations were higher in both the biofilm and the bulk liquid. Regarding nitrification, the higher values were attributed to a lower removal of Xs in the aerobic reactors and accordingly, a lower accumulation of heterotrophic biomass in the biofilm was found in the simulations.

Genetic analysis of the LGI/Epitempin gene family in sporadic and familial lateral temporal lobe epilepsy

Mutations in the LGI1/Epitempin gene cause autosomal dominant lateral temporal lobe epilepsy (ADLTE), a partial epilepsy characterized by the presence of auditory seizures. However, not all the pedigrees with a phenotype consistent with ADLTE show mutations in LGI1/Epitempin, or evidence for linkage to the 10q24 locus. Other authors as well as ourselves have found an internal repeat (EPTP, pfam# PF03736) that allowed the identification of three other genes sharing a sequence and structural similarity with LGI1/Epitempin. In this work, we present the sequencing of these genes in a set of ADLTE families without mutations in both LGI1/Epitempin and sporadic cases. No analyzed polymorphisms modified susceptibility in either the familial or sporadic forms of this partial epilepsy.

Comparison between two cord blood collection strategies

BACKGROUND AND OBJECTIVES

Collection strategy is the first step for collecting good quality cord blood (CB) units. There are two principal different techniques to collect CB from the umbilical vein: in the delivery room while the placenta is still in the uterus by midwives and obstetricians or in an adjacent room after placental delivery by CB-bank trained personnel. In this study, the benefits and disadvantages between two different CB collection strategies were evaluated in order to improve CB bank methodology.

DESIGN AND METHODS

Valencia CB bank maintains the two different collection strategies aforementioned. Before processing CB units, volume was calculated and samples were drawn for cell counts. After processing and before cryopreservation, samples for cell counts, CD34 analysis, viability, clonogenic assays and microbiology were drawn directly from the bags. We compared the efficiency of the two collection techniques.

RESULTS

Obstetric date and umbilical CB was obtained from 848 vaginal (484 collected in uterus and 364 collected ex uterus). The proportion of excluded CB units before processing was 33% for ex uterus and 25% for in uterus. The difference was statistically significant. A larger volume and a higher number of total nucleated cells, CD34+ cells and CFUs were harvested in the in uterus collection group.

INTERPRETATION AND CONCLUSIONS

Based on our findings, we conclude that the mode of collection influences the hematopoietic content of CB donations. Collection before placental delivery is the best approach to CB collection and allows optimizing CB bank methodology.

Comparison between two strategies for umbilical cord blood collection

The use of cord blood (CB) for transplantation has increased greatly in recent years. The collection strategy is the first step in collecting good-quality CB units. There are two main techniques for collecting CB from the umbilical vein: in the delivery room while the placenta is still in the uterus by midwives and obstetricians or in an adjacent room after placental delivery by CB bank trained personnel. In this study, the benefits and disadvantages between the two different CB collection strategies were evaluated, in order to improve CB bank methodology. Valencia CB bank maintains the two different collection strategies. CB was obtained from 569 vaginal and 70 caesarean deliveries and obstetrical and clinical charts were reviewed. Before processing CB units, volume was calculated and samples were drawn for cell counts. After processing and before cryopreservation samples were drawn for cell counts, CD34+cell analysis, viability, clonogenic assays and microbiology were drawn directly from the bags. We compared the efficiency of the two collection techniques. Obstetric data and umbilical CB were obtained from 569 vaginal (264 collected in utero and 305 collected ex utero) and 70 caesarean deliveries. The proportion of excluded CB units before processing was 33% for vaginal ex utero, 25% for vaginal in utero and 46% for caesarean deliveries. Differences were statistically significant. For vaginal deliveries a larger volume and a higher number of nucleated cells, percentage of CD34+ cells and colony-forming units (CFUs) were harvested in the in utero collection group. There was no statistical difference between CB collected after placental expulsion from vaginal and caesarean deliveries. Comparison between all vaginal and caesarean deliveries did not show any difference. We conclude that the mode of collection influences the haematopoietic content of CB donations. Collection before placental delivery is the best approach to CB collection and allows optimisation of CB bank methodology. Caesarean deliveries seem to contain similar progenitor content to vaginal deliveries.

Optimizing nitrogen removal in the BioDenitro process

The potential and limits of different configurations of the BioDenitro-alternating process to suit the various design cases that can arise depending on the wastewater characteristics, space necessary and effluent nitrogen requirements were analysed through simulations of the activated sludge model No. 2. The first analysis involved the combination in one cycle of the main phase in the alternating reactors with an aerated phase having the two reactors in aerobic conditions and/or a hydraulic phase using the flow only in the anoxic reactor. This option has been found to have a very high potential for cases with strict requirements concerning effluent total nitrogen, but limited when the requirements are low effluent NH4-N, relatively high effluent total nitrogen and minimum solids and hydraulic retention times. When the latter conditions have to be fulfilled the incorporation of a post-aeration reactor to the alternating reactor was found to be very effective. In addition the configuration is very flexible because multiple combinations of post-aeration reactor volumes and in the duration of the different phases in the alternating reactors can be selected to achieve effluent nitrogen requirements. This flexibility is limited to the use of moderate values in the post-aeration reactor volumes and in the duration of the aerated phase. An experimental trial of the latter configuration was carried out and demonstrated its operational simplicity by achieving the desired nitrogen requirements in the effluent simply by changing the duration of the aerated phase for a given post-aeration reactor volume. From the experimental results an enhanced simultaneous nitrification-denitrification at the start of aeration in the alternating reactors was found and the ASM2 model was shown to have a satisfactory predictive capacity.

Improving nitrogen removal in predenitrification-nitrification biofilters

The effect on NH4-N removal rates in nitrification biofilters of filtered biodegradable COD and particulate COD leaving predenitrification biofilters was studied in a lab scale plant configured with the separated system of biofilters for secondary nitrogen removal from urban wastewaters. Applying a typical COD load of 11 kg/m3 x day to the predenitrification biofilter and maximizing its COD removal by adding nitrates or by operating an improved control of the internal recycle, only 60% removal of filtered biodegradable COD was found. This value corresponds to the complete removal of the readily biodegradable substrate (30% of influent filtered COD) and 36% of filtered slowly biodegradable substrate (50% of influent COD). The remaining 64% of the latter entered the nitrification biofilter, causing competition between heterotrophs and nitrifiers for dissolved oxygen in the inner layers of the biofilm. Consequently the nitrification rate had relatively low values (0.5 kgN/m3 x d) at 14 degrees C despite using dissolved oxygen levels of 6 mg/l. This behaviour may explain the lower nitrification rates obtained in some cases of nitrification biofilters compared to those in tertiary nitrification after activated sludge processes. The particulate COD entering the nitrification biofilter is associated with the suspended solids leaving the denitrification biofilter which are adsorbed by the external layers of the biofilm, increasing its thickness. The activity of the nitrifiers was affected because of a lack of oxygen when the thickness was left to grow considerably. Therefore no significant particulate COD effect is expected to occur as long as backwashing is carried out with the appropriate frequency.

Improving the predictions of ASM2d through modelling in practice

The paper presents the adjustments carried out on the structure and in some default values of the kinetic coefficients of the ASM2d model in order to get an improved prediction for the experimental results obtained in pilot scale plants studies with different activated sludge treatment processes for carbon, nitrogen and phosphorous removal. In order to predict the high effluent filtered COD experimentally observed in high rate processes for carbon removal, a new model structure has been proposed, incorporating into the carbon model a soluble fraction of the slowly biodegradable substrate. Studies with the step feed and the alternating processes showed simultaneous nitrification-denitrification in aerated reactors which was predicted with increased values in the oxygen saturation coefficients for heterotrophic and autotrophic biomass. Both processes also showed loss of the denitrification capacity under unfavourable conditions, such us rains and low anoxic fraction, which required a very large decrease in the value of the reduction factor for denitrification so as to improve the predictions for effluent nitrate experimental results. Regarding phosphorus removal, the ASM2d model showed a satisfactory predictive capacity. For improved predictions of phosphorus release in anaerobic conditions, high values of the rate constant for storage of X(PHA) and low values of the anaerobic hydrolysis reduction factor were used. For phosphorus uptake in aerobic and anoxic conditions satisfactory predictions were obtained using the default values.

Standardized, unrelated donor cord blood transplantation in adults with hematologic malignancies

The potential role of unrelated donor cord blood transplantation (UD-CBT) in adults remains unclear. This study reports the results of UD-CBT in 22 adults with hematologic malignancies following conditioning with thiotepa, busulfan, cyclophosphamide, and antithymocyte globulin in 21, with thiotepa, fludarabine, and antithymocyte globulin in 1, and graft-versus-host disease (GVHD) prophylaxis with cyclosporine and prednisone. Median age was 29 years (range, 18-46 years), and median weight was 69.5 kg (range, 41-85 kg). HLA match was 6 of 6 in 1 case, 5 of 6 in 13 cases, and 4 of 6 in 8 cases. Median number of nucleated cells infused was 1.71 x 10(7)/kg (range, 1.01 x 10(7)/kg to 4.96 x 10(7)/kg). All 20 patients surviving more than 30 days had myeloid engraftment, and only 1, who received the lowest cell dose, developed secondary graft failure. Median time to reach an absolute neutrophil count of at least 0.5 x 10(9)/L was 22 days (range, 13-52 days). Median time to platelets numbered at least 20 x 10(9)/L was 69 days (range, 49-153 days). Seven patients (32%) developed acute GVHD above grade II, and 9 of 10 patients at risk developed chronic GVHD, which became extensive in 4 patients. Twelve patients remained alive and disease-free 3 to 45 months after transplantation. Disease-free survival (DFS) at 1 year was 53%. Age strongly influenced DFS (P =.01). For patients aged 30 years or younger, the DFS at 1 year was 73%. These preliminary results suggest that UD-CBT should be considered a reasonable alternative in young adults with hematologic malignancy and no appropriate bone marrow donor.

Role of methylene blue-treated or fresh-frozen plasma in the response to plasma exchange in patients with thrombotic thrombocytopenic purpura

Twenty patients with thrombotic thrombocytopenic purpura (TTP) underwent plasma exchange using either standard fresh-frozen plasma (Group A, n = 13) or methylene blue-treated plasma (Group B, n = 7). Both groups presented similar characteristics except that bilirubin values were higher in Group A (P < 0.05). The complete remission rate was higher in Group A than B (69% versus 57%). The mean number of procedures was higher in Group B (21 +/- 7 versus 11 +/- 3, P < 0.01) and the mean duration of hospitalization was also longer (37 +/- 12 d versus 22 +/- 11 d; P < 0.01). Our study shows that the use of methylene blue-treated fresh-frozen plasma to treat TTP is associated with a higher number of plasma exchanges and greater transfusion requirements without improving clinical results.

Unrelated donor cord blood transplantation in adults with chronic myelogenous leukemia: results in nine patients from a single institution

The potential role of unrelated donor cord blood transplantation (UD-CBT) in adults is not well established. We report the results of UD-CBT in nine adult patients with chronic myeloid leukemia (CML). The median age was 27 years (range, 19-41 years), and the median weight was 62 kg (range, 45-78 kg). At transplant, six patients were in chronic phase (five in first, and one in second), two in blast crisis, and one in accelerated phase. Eight had received intensive chemotherapy, and three had undergone autologous peripheral blood hematopoietic stem cell transplantation. Four had received interferon with no cytogenetic response, and only three underwent UD-CBT within 1 year of diagnosis. After serological typing for class I antigens, and high-resolution DNA typing for DRB1, the degree of HLA match between patients and cord blood (CB) units was 4/6 in six cases and 5/6 in three cases. The median number of nucleated cells infused was 1.7 x 10(7)/kg (range, 1.2 to 4.9 x 10(7)/kg), and was above 2 x 10(7)/kg in only two cases. All patients received thiotepa, busulfan, cyclophosphamide and anti-thymocyte globulin as conditioning; cyclosporine and prednisone for graft-versus-host disease (GVHD) prophylaxis; and G-CSF from day +7 until engraftment. All seven evaluable cases engrafted. The median time to reach an absolute neutrophil count > or =0.5 x 10(9)/l and > or =1 x 10(9)/l was 22 days (range, 19-52 days) and 28 days (range, 23-64 days), respectively. In the four patients evaluable for platelet recovery time to levels of > or =20 x 10(9) platelets/l, > or =50 x 10(9) platelets/l, and > or =100 x 10(9) platelets/l, these ranged from 50 to 128 days, 60 to 139 days, and 105 to 167 days, respectively. Three patients developed acute GVHD above grade II, and three of the five patients at risk developed extensive chronic GVHD. Four patients, all transplanted in chronic phase, remain alive in molecular remission more than 18, 19, 24 and 42 months after transplantation. These preliminary results suggest that UD-CBT may be considered a reasonable alternative in adults with CML who lack an appropriate bone marrow donor.

New simulators for the optimum management and operation of wastewater treatment plant

This paper presents the basic description and the first full-scale implementation of a new kind of simulator specially designed to facilitate and improve the management and operation of modern wastewater treatment plants (WWTP). This new kind of simulator for plant operation is specifically adapted to every WWTP and the software is developed considering the common needs of the operators in plant exploitation. The internal structure of the plant operation simulator is based on a complete connection between the real data and the mathematical model of the plant. The software is then able to perform the processing, storage and management of the plant data and to predict the evolution of the process reading the required inputs from its stored files. The results obtained with the first application recommend the implementation of this new kind of simulators for plant operation in other treatment plants. However, it is important to note that the application of this technology implies a systematic and rigorous methodology in the acquisition and processing of the most significant plant data.

Development and verification of design and operation criteria for the step feed process with nitrogen removal

The step feed process with three stages of denitrification-nitrification reactors has been studied using simulations in order to develop criteria for the optimum selection of the design parameters and to propose efficient operational strategies. To verify the simulation results experimental studies in a pilot plant of 1100 litres were carried out. The simulation studies showed that the optimum influent flow distribution to the three anoxic reactors is in the range of 40-40-20% and 33-33-34% depending on the wastewater characteristics and effluent requirements. These two latter conditions and in turn the influent flow distribution determine the anoxic and aerobic reactor volumes. The reduction of the dissolved oxygen in the two first aerobic reactors and the use of facultative zones in the final D-N stage are proposed as operational strategy. The experimental results proved the validity of the criteria developed for design and operation. A high capacity of the IAWQ activated sludge model No. 1 to predict the performance of the step feed process was observed.

Cutaneous promyelocytic sarcoma at sites of vascular access and marrow aspiration. A characteristic localization of chloromas in acute promyelocytic leukemia?

Extramedullary disease (EMD) is a rare clinical event in acute promyelocytic leukemia (APL). Although the skin is involved in half of the reported EMD cases, the occurrence of cutaneous promyelocytic sarcoma (PS) has been described very rarely. We report here three cases of PS which have the peculiarity of appearing at sites of punctures for arterial and venous blood and marrow samples (sternal manubrium, antecubital fossa, wrist over the radial artery pulse, catheter insertion scar). At presentation, all patients had hyperleukocytosis and a morphologic diagnosis of microgranular acute promyelocytic leukemia variant confirmed at the genetic level by demonstration of the specific chromosomal translocation t(15;17). A BCR3 type PML/RARa transcript was documented in the two patients for whom diagnostic RT-PCR was available. Patients had morphologic bone marrow remission at the time the PS appeared. A predilection for the development of cutaneous PS at sites of previous vascular damage has been noted, but the pathogenesis remains largely unknown. A potential role for all-trans retinoic acid has been advocated, although one of the three patients in our series had received no ATRA. A review of the literature revealed six similar cases and hyperleukocytosis at diagnosis was a consistent finding in all of them. A careful physical examination of these particular sites in the follow-up of patients at risk, as well as cutaneous biopsy and laboratory examination of suspected lesions are strongly recommended.

Carboplatin plus cytarabine in the treatment of high-risk acute myeloblastic leukemia

Thirty-one patients (20 male and 11 female; median age 51 years (16-79)) with high-risk acute myeloblastic leukemia (AML) (20 refractory AML and 11 secondary AML (s-AML) (four to myelodysplastic syndrome, five to chemo/radiotherapy, one to aplastic anemia and one blastic chronic myelogenous leukemia (B-CML)) were treated with CBDCA (300 mg/m2/day x 5 days in continuous i.v. infusion) plus intermediate-dose Ara-C (500 mg/m2/day x 3 days in rapid i.v. infusion). Nine patients (29%) achieved CR (five s-AML (three myelodysplastic syndromes, one CML and one ALL) and four refractory AML) and 11 patients had resistant disease. There were 11 early deaths (35%). Median disease-free survival of the nine responders was 4 months. The main toxicity was hematological, febrile episodes took place in nearly all the patients (96%). The CBDCA plus Ara-C regimen showed an evident antileukemic activity in high-risk leukemia. However, the lack of long-term disease-free survivors shows the need for innovative postremission strategies. The high initial response rate seen in AML secondary to myelodysplastic syndromes (MDS) warrants further investigation of CBDCA in combination regimens for MDS patients.

[Lymphocyte subsets in blood donors]

OBJECTIVES

To establish the normal values among the different lymphocyte subsets in peripheral blood, measured by surface antigen expression, in healthy population. To observe if there are potential differences in respect of age, gender or sample origin. To compare the absolute lymphocyte number obtained with flow cytometry and with a cellular counter.

MATERIAL AND METHODS

Longitudinal and prospective study performed with 100 samples of blood donors. Direct immunofluorescence with triple color staining was made on whole blood, red blood cells were then lysed and samples were analysed with a flow cytometer. The lymphocyte subsets studied were the T lymphocytes and their subsets (CD4 and CD8 lymphocytes), the B lymphocytes and Natural Killer cells population. The absolute lymphocyte count was performed with an automatic cellular counter. Donor data such as age, gender and origin were recorded and were statistically analysed.

RESULTS

Normal ranges from the studied parameters are similar to other series. Comparison with gender, origin or age groups gave no significant difference, although there seems to be a tendency to decrease with the ageing of the population. Total absolute lymphocyte number did not differ between the results from the cellular counter or from the flow cytometer.

CONCLUSIONS

We found no differences in the absolute lymphocyte number nor in the lymphocyte subsets studied (T lymphocytes, CD4 lymphocytes, CD8 lymphocytes, B lymphocytes and NK cells) with respect to gender, age or sample source. We have established reference ranges for our laboratory. We have not found significant differences in the absolute lymphocyte number measured with cell counter or with flow cytometer.

[Invasive fungal infections in patients with blood disorders]

BACKGROUND

Invasive fungal infections (IFI) are severe infectious complications frequently observed in patients with hematological disorders. The aims of this study were to analyse the characteristics of this particular type of infection in a large series of a single institution and to determine the factors associated with the outcome and therapeutic response.

PATIENTS AND METHODS

This study reviews the clinical and microbiological features of 155 IFI occurred among 144 patients with hematologic disorders throughout a period of 17 years in a single institution.

RESULTS

In 118 cases (82%) the diagnosis was acute leukemia. The main risk factors for developing IFI included a persistent and profound granulocytopenia, the use of broad-spectrum antibacterial agents, indwelling central venous catheters and the damage of normal host barriers following intensive cytotoxic chemotherapy. Candida (65 cases [44%]) and Aspergillus (38 cases [26%]) species were the most common fungal species isolated. An increasing number of IFI were caused by fungi previously considered as contaminants or harmless colonizers. The outcome of IFI was favourable in 78 cases (50%). The most important prognostic factors for the outcome of the IFI were the phase of cytotoxic chemotherapy (p = 0.005), the response of the underlying disease to the cytotoxic chemotherapy (p < 0.00001), and the recovery of neutropenia during the infection course (p < 0.00001). An earlier use of empirical antifungal therapy was also associated with a better outcome.

CONCLUSIONS

In spite of earlier treatment and regardless the development of new antifungal agents, the prognosis of IFI in patients with hematological malignancies remains poor. The use of hematopoietic growth factors, through their impact in the duration and severity of neutropenia, may prove valuable the management of IFI in this setting.

[Monotherapy with meropenem in febrile granulocytopenic patients]

Infection remains the major cause of morbidity and mortality for cancer patients who become granulocytopenic. Combinations of beta-lactams plus aminoglycosides have been the standard empiric therapy for febrile granulocytopenic patients, especially those with profound long-lasting granulocytopenia. The advent of new broad-spectrum cephalosporins and carbapenems has favoured the possibility of empiric monotherapy. Meropenem is a parenteral carbapenem antibiotic stable to renal dehydropeptidase-I which has excellent bactericidal activity against almost all clinically significant aerobic and anaerobic organisms. Meropenem hasta an antibacterial spectrum similar to that of imipenem but it is more active against Pseudomonas aeruginosa, all Enterobacteriaceae, Haemophilus influenzae, Proteus spp, Morganella spp and Providencia spp. Recently, the efficacy, safety, and tolerance of meropenem monotherapy for the empirical treatment of fever in granulocytopenic cancer patients have been compared in two large prospective randomized multicenter trials. The Meropenem Study Group compared monotherapy with meropenem versus ceftazidime and the EORTC conducted a comparative study of meropenem monotherapy versus the combination of ceftazidime plus amikacin. In both groups, success rates were similar by type of infection and infection-related mortality was low. Related adverse events were also similar in both groups. These studies confirm that monotherapy with meropenem is as effective as ceftazidime-containing regimens for the empiric treatment of fever in granulocytopenic patients.

Cardiac tamponade and cardiogenic shock as a manifestation of all-trans retinoic acid syndrome: an association not previously reported

Since the discovery of the differentiating activity of all-trans retinoic acid (ATRA) in acute promyelocytic leukemia (APL), the treatment of this disease has greatly improved. Currently, the combination of ATRA and chemotherapy is considered the best treatment for patients with APL. This approach has consistently extended the remission rate and disease-free survival of APL patients with low mortality. Among ATRA's adverse effects, the retinoic acid syndrome is the most important. It consists of fever, dyspnea, weight gain, pulmonary infiltrates and pleural and cardiac effusions. Other findings occasionally described are lower extremities edema and leukocytosis. We report a case of an retinoic acid syndrome associated with cardiac tamponade due to massive pericardial effusion. This adverse effect, not previously reported, was successfully treated by performing pericardiocentesis followed by the administration of dexamethasone.